Provider Demographics
NPI:1841861234
Name:BOTKINS, RICHARD MICHAEL (PRSS)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:MICHAEL
Last Name:BOTKINS
Suffix:
Gender:M
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 WASHINGTON ST E
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25311-2511
Mailing Address - Country:US
Mailing Address - Phone:304-414-5949
Mailing Address - Fax:
Practice Address - Street 1:1520 WASHINGTON ST E
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25311-2511
Practice Address - Country:US
Practice Address - Phone:304-414-5949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-07
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18-916175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist