1689859704 NPI number — MARK LEROY BOTTELSON O.D.

Table of content: MARK LEROY BOTTELSON O.D. (NPI 1689859704)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689859704 NPI number — MARK LEROY BOTTELSON O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOTTELSON
Provider First Name:
MARK
Provider Middle Name:
LEROY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.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:
1689859704
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1001 73RD ST
Provider Second Line Business Mailing Address:
VISION CENTER
Provider Business Mailing Address City Name:
WINDSOR HEIGHTS
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50324-1311
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-274-6452
Provider Business Mailing Address Fax Number:
515-274-6306

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 73RD ST
Provider Second Line Business Practice Location Address:
VISION CENTER
Provider Business Practice Location Address City Name:
WINDSOR HEIGHTS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50324-1311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-274-6452
Provider Business Practice Location Address Fax Number:
515-274-6306
Provider Enumeration Date:
01/08/2008

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: 152W00000X , with the licence number:  01684 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 238377 . This is a "COVENTRY" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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