Provider Demographics
NPI:1811994569
Name:BOETTGER, MARK (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:BOETTGER
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 1:500 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTOLA
Mailing Address - State:CA
Mailing Address - Zip Code:96122-9406
Mailing Address - Country:US
Mailing Address - Phone:530-832-6500
Mailing Address - Fax:
Practice Address - Street 1:500 1ST AVE
Practice Address - Street 2:
Practice Address - City:PORTOLA
Practice Address - State:CA
Practice Address - Zip Code:96122-9406
Practice Address - Country:US
Practice Address - Phone:530-832-6500
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-07
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39579207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F13116Medicare UPIN