Provider Demographics
NPI:1457506347
Name:BOTTS, JONATHAN D (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:D
Last Name:BOTTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4955 VAN NUYS BLVD
Mailing Address - Street 2:SUITE 615
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1801
Mailing Address - Country:US
Mailing Address - Phone:818-905-2222
Mailing Address - Fax:818-905-8702
Practice Address - Street 1:4955 VAN NUYS BLVD
Practice Address - Street 2:SUITE 615
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1801
Practice Address - Country:US
Practice Address - Phone:818-905-2222
Practice Address - Fax:818-905-8702
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-19
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA 117042174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADA0572OtherRAILROAD
CA0368280002Medicare NSC
CAW11945AMedicare PIN
CADA0572OtherRAILROAD
CA0368280001Medicare NSC