Provider Demographics
NPI:1750382339
Name:BOTNICK, WARREN C (MD)
Entity type:Individual
Prefix:
First Name:WARREN
Middle Name:C
Last Name:BOTNICK
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 2475
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-2475
Mailing Address - Country:US
Mailing Address - Phone:318-214-5770
Mailing Address - Fax:
Practice Address - Street 1:601 KEYSER AVE
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-6020
Practice Address - Country:US
Practice Address - Phone:318-214-5770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.207802207RC0200X, 207RS0012X, 207RP1001X, 207RS0012X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000862738BMedicaid
GA29BDCJQMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
GAE04673Medicare UPIN