1235199373 NPI number — RONALD J BOTELHO M.D.

Table of content: RONALD J BOTELHO M.D. (NPI 1235199373)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235199373 NPI number — RONALD J BOTELHO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOTELHO
Provider First Name:
RONALD
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1235199373
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 14578
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA ROSA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95402-6578
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-569-3230
Provider Business Mailing Address Fax Number:
707-523-0119

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1221 FARMERS LN
Provider Second Line Business Practice Location Address:
SUITE 500
Provider Business Practice Location Address City Name:
SANTA ROSA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95405-6712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-569-3230
Provider Business Practice Location Address Fax Number:
707-523-0119
Provider Enumeration Date:
03/24/2006

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: 207L00000X , with the licence number:  10484 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X , with the licence number: G53308 , 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: 100501809 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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