1881705838 NPI number — DR. GINO BOTTINO MD

Table of content: DR. GINO BOTTINO MD (NPI 1881705838)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881705838 NPI number — DR. GINO BOTTINO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOTTINO
Provider First Name:
GINO
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1881705838
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 WASHINGTON ST STE 220
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORWICH
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06360-2700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-886-8362
Provider Business Mailing Address Fax Number:
860-886-9262

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1701 W SAINT MARYS RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85745-2621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-276-2270
Provider Business Practice Location Address Fax Number:
520-585-5827
Provider Enumeration Date:
08/31/2006

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: 207RH0000X , with the licence number:  C1-0025452 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0003X , with the licence number: 137196-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RX0202X , with the licence number: C1-0025452 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0003X , with the licence number: 55107 , 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: 00826499 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".