Healthcare Provider Details

I. General information

NPI: 1336335959
Provider Name (Legal Business Name): CAROL A. BOTTJER OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2007
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12220 STATE HIGHWAY 14 N SUITE 3
CEDAR CREST NM
87008-1640
US

IV. Provider business mailing address

PO BOX 1640
CEDAR CREST NM
87008-1640
US

V. Phone/Fax

Practice location:
  • Phone: 505-286-0300
  • Fax: 505-286-7754
Mailing address:
  • Phone: 505-286-0300
  • Fax: 505-286-7754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1668DT
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number661
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: