Provider Demographics
NPI:1841440096
Name:BOTU, DEVI PRASAD (MD)
Entity type:Individual
Prefix:
First Name:DEVI PRASAD
Middle Name:
Last Name:BOTU
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 1:119 BOONE RIDGE DRIVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37615
Mailing Address - Country:US
Mailing Address - Phone:423-282-1480
Mailing Address - Fax:423-928-1353
Practice Address - Street 1:130 W, RAVINE RD.
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660
Practice Address - Country:US
Practice Address - Phone:423-224-3450
Practice Address - Fax:423-224-3458
Is Sole Proprietor?:No
Enumeration Date:2008-09-24
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN47660207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist