Provider Demographics
NPI:1881777803
Name:BOTKISS, PHILIP HENRY (MD)
Entity type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:HENRY
Last Name:BOTKISS
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 712878
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92171-2878
Mailing Address - Country:US
Mailing Address - Phone:619-291-7100
Mailing Address - Fax:619-291-3040
Practice Address - Street 1:220 HIGHLAND DRIVE
Practice Address - Street 2:SUITE # 105
Practice Address - City:SOLANO BEACH
Practice Address - State:CA
Practice Address - Zip Code:92075
Practice Address - Country:US
Practice Address - Phone:619-291-7100
Practice Address - Fax:619-291-3040
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA432732084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A432730Medicaid
E02533Medicare UPIN
A43273Medicare ID - Type Unspecified