Provider Demographics
NPI:1740279470
Name:MARK L. BOTTELSON, O.D. AND ASSOCIATES, P.C.
Entity type:Organization
Organization Name:MARK L. BOTTELSON, O.D. AND ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:RAHE
Authorized Official - Last Name:BOTTELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-274-6452
Mailing Address - Street 1:1001 73RD ST
Mailing Address - Street 2:VISION CENTER
Mailing Address - City:WINDSOR HEIGHTS
Mailing Address - State:IA
Mailing Address - Zip Code:50324-1311
Mailing Address - Country:US
Mailing Address - Phone:515-274-6452
Mailing Address - Fax:515-274-6306
Practice Address - Street 1:1001 73RD ST
Practice Address - Street 2:VISION CENTER
Practice Address - City:WINDSOR HEIGHTS
Practice Address - State:IA
Practice Address - Zip Code:50324-1311
Practice Address - Country:US
Practice Address - Phone:515-274-6452
Practice Address - Fax:515-274-6306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-15
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1684152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
551764OtherNATIONAL VISION ADMIN.
IA6151OtherMIDLANDS CHOICE
9391471OtherPRIVATE HEALTH CARE SYSTE
IA36759OtherBLUE CROSS BLUE SHIELD
IA3167973Medicaid
IA6151OtherMIDLANDS CHOICE
551764OtherNATIONAL VISION ADMIN.
IA=========OtherTRICARE
IA36759OtherBLUE CROSS BLUE SHIELD
IA=========OtherUNITED HEALTH CARE