Provider Demographics
NPI:1649309691
Name:BOTTS, ROBERT ELAM (OD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ELAM
Last Name:BOTTS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO DRAWER BB
Mailing Address - Street 2:
Mailing Address - City:BIG STONE GAP
Mailing Address - State:VA
Mailing Address - Zip Code:24219-0660
Mailing Address - Country:US
Mailing Address - Phone:276-523-4414
Mailing Address - Fax:276-523-4414
Practice Address - Street 1:606 POWELL AVE E
Practice Address - Street 2:
Practice Address - City:BIG STONE GAP
Practice Address - State:VA
Practice Address - Zip Code:24219-2348
Practice Address - Country:US
Practice Address - Phone:276-523-4414
Practice Address - Fax:276-523-4414
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000016152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA021081OtherANTHEM BSG
VA38670OtherDAVIS VISION
VA098665OtherANTHEM PENNINGTON
VA009201068Medicaid
VA009204334Medicaid
VA410024243Medicare ID - Type UnspecifiedPERF PROV RR MEDICARE
VAT87432Medicare UPIN
VA098665OtherANTHEM PENNINGTON
VA0908525Medicare ID - Type UnspecifiedMEDICARE UMWA
VA009201068Medicaid