Healthcare Provider Details

I. General information

NPI: 1649375239
Provider Name (Legal Business Name): CARMEN JULIA BOTERO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 10/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5353 BALBOA BLVD STE 201
ENCINO CA
91316-2865
US

IV. Provider business mailing address

PO BOX 571027
TARZANA CA
91357-1027
US

V. Phone/Fax

Practice location:
  • Phone: 818-788-5437
  • Fax: 818-788-5436
Mailing address:
  • Phone: 818-343-5794
  • Fax: 919-343-5793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA47742
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberA47742
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberA47742
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: