Provider Demographics
NPI:1982613790
Name:BOTT, MATTHEW S (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:S
Last Name:BOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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Mailing Address - Street 1:11810 NICHOLAS ST STE 101
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-4414
Mailing Address - Country:US
Mailing Address - Phone:402-779-8400
Mailing Address - Fax:402-779-8401
Practice Address - Street 1:11810 NICHOLAS ST STE 101
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-4414
Practice Address - Country:US
Practice Address - Phone:402-779-8400
Practice Address - Fax:402-779-8401
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE22907207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
279487Medicare ID - Type Unspecified