Healthcare Provider Details

I. General information

NPI: 1891764577
Provider Name (Legal Business Name): JOEL L BOTLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 03/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 MARGINAL WAY SUITE 700
PORTLAND ME
04101-2443
US

IV. Provider business mailing address

100 FODEN RD, WEST SUITE 203
SOUTH PORTLAND ME
04106-2319
US

V. Phone/Fax

Practice location:
  • Phone: 207-774-5816
  • Fax: 207-523-8597
Mailing address:
  • Phone: 207-828-0361
  • Fax: 207-874-1483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number010885
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number010885
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: