Provider Demographics
NPI:1457566341
Name:BOTHUELL, CHANTALE ESTHER (DPM)
Entity Type:Individual
Prefix:DR
First Name:CHANTALE
Middle Name:ESTHER
Last Name:BOTHUELL
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 FORDHAM ST
Mailing Address - Street 2:
Mailing Address - City:KEEGO HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48320-1412
Mailing Address - Country:US
Mailing Address - Phone:313-384-7300
Mailing Address - Fax:248-747-4014
Practice Address - Street 1:2424 FORDHAM ST
Practice Address - Street 2:
Practice Address - City:KEEGO HARBOR
Practice Address - State:MI
Practice Address - Zip Code:48320-1412
Practice Address - Country:US
Practice Address - Phone:313-384-7300
Practice Address - Fax:248-747-4014
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002140213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2265017Medicaid
MIMI3990Medicare UPIN