Provider Demographics
NPI:1780887166
Name:BOTKER, JESSE COLE (MD)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:COLE
Last Name:BOTKER
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 1:1431 PREMIER DR
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-6076
Mailing Address - Country:US
Mailing Address - Phone:507-386-6600
Mailing Address - Fax:507-625-5971
Practice Address - Street 1:1431 PREMIER DR
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6076
Practice Address - Country:US
Practice Address - Phone:507-386-6600
Practice Address - Fax:507-625-5971
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN17798207X00000X
CAA107192207X00000X
MN52645207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1780887166OtherPREFERRED ONE
MN09-03588OtherMEDICA
MN1780887166OtherUCARE
MN1780887166OtherCORVEL
MN1780887166OtherTRICARE
MN138248000OtherUS DOL
MN1780887166OtherBLUE CROSS BLUE SHIELD OF MN
MN1780887166OtherHEALTHPARTNERS
MN1780887166OtherAMERICA'S PPO
MN1780887166OtherMMSI
MN1780887166Medicaid
MN1780887166OtherBLUE CROSS BLUE SHIELD OF MN