Healthcare Provider Details

I. General information

NPI: 1265111900
Provider Name (Legal Business Name): DR. JUAN BOTERO-GIRALDO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2023
Last Update Date: 07/24/2025
Certification Date: 07/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 MONTGOMERY HWY STE 1
DOTHAN AL
36303-1270
US

IV. Provider business mailing address

6115 GRANTON AVE APT 6L
NORTH BERGEN NJ
07047-3326
US

V. Phone/Fax

Practice location:
  • Phone: 334-803-8700
  • Fax:
Mailing address:
  • Phone: 551-497-0859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD.007543-C1
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: