=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033192844
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARC I BOTNICK MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2005
-----------------------------------------------------
Last Update Date | 06/01/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18133 VENTURA BLVD STE 102
-----------------------------------------------------
City | TARZANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91356-3641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-314-7695
-----------------------------------------------------
Fax | 424-314-7699
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4140 W 190TH ST
-----------------------------------------------------
City | TORRANCE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90504-5513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | A72882
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0001X
-----------------------------------------------------
Taxonomy Name | Radiation Oncology Physician
-----------------------------------------------------
License Number | A72882
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------