Healthcare Provider Details

I. General information

NPI: 1457358160
Provider Name (Legal Business Name): MAURICIO BOTERO-VELEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 10/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 FAHY ST
BELFAST ME
04915
US

IV. Provider business mailing address

10470 SW 66TH ST
MIAMI FL
33173-1358
US

V. Phone/Fax

Practice location:
  • Phone: 207-505-4304
  • Fax:
Mailing address:
  • Phone: 772-933-9432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberMD23464
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number77117
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: