Provider Demographics
NPI:1457587123
Name:BOOTWALA, ZOEB (MD)
Entity Type:Individual
Prefix:
First Name:ZOEB
Middle Name:
Last Name:BOOTWALA
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:PO BOX 5048
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31208-5048
Mailing Address - Country:US
Mailing Address - Phone:478-918-0770
Mailing Address - Fax:478-918-0771
Practice Address - Street 1:1531 WATSON BLVD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-3449
Practice Address - Country:US
Practice Address - Phone:478-599-0110
Practice Address - Fax:478-599-0001
Is Sole Proprietor?:No
Enumeration Date:2009-06-08
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA71098207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine