Healthcare Provider Details

I. General information

NPI: 1063631802
Provider Name (Legal Business Name): CARMEN BOTERO, MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18321 CLARK ST
TARZANA CA
91356-3501
US

IV. Provider business mailing address

PO BOX 570587
TARZANA CA
91357-0587
US

V. Phone/Fax

Practice location:
  • Phone: 208-676-9080
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KAREN HALE
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 208-762-6836