Healthcare Provider Details

I. General information

NPI: 1740279470
Provider Name (Legal Business Name): MARK L. BOTTELSON, O.D. AND ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2005
Last Update Date: 07/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 73RD ST VISION CENTER
WINDSOR HEIGHTS IA
50324-1311
US

IV. Provider business mailing address

1001 73RD ST VISION CENTER
WINDSOR HEIGHTS IA
50324-1311
US

V. Phone/Fax

Practice location:
  • Phone: 515-274-6452
  • Fax: 515-274-6306
Mailing address:
  • Phone: 515-274-6452
  • Fax: 515-274-6306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1684
License Number StateIA

VIII. Authorized Official

Name: MRS. ELAINE RAHE BOTTELSON
Title or Position: INSURANCE MANAGER
Credential:
Phone: 515-274-6452