1861612731 NPI number — DR. ROSANNE LESLEY BOTHA M.D.

Table of content: DR. ROSANNE LESLEY BOTHA M.D. (NPI 1861612731)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861612731 NPI number — DR. ROSANNE LESLEY BOTHA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOTHA
Provider First Name:
ROSANNE
Provider Middle Name:
LESLEY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861612731
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 60000
Provider Second Line Business Mailing Address:
FILE 74175
Provider Business Mailing Address City Name:
SAN FRANCISCO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94160-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
415-641-2177
Provider Business Mailing Address Fax Number:
415-641-2190

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1580 VALENCIA ST
Provider Second Line Business Practice Location Address:
STE 508
Provider Business Practice Location Address City Name:
SAN FRANCISCO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94110-4423
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-641-2140
Provider Business Practice Location Address Fax Number:
415-641-2150
Provider Enumeration Date:
04/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  A94103 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00A941030 . This is a "MEDICARE ID - TYPE UNSPECIFIED" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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