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General NPI Number Information
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NPI Number | 1124227772
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Entity Type | Individual
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Provider Name | ISSA M BOTROS MD
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Gender | Male
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Dates
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Enumeration Date | 07/13/2007
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Last Update Date | 11/30/2021
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Provider Practice Location Address
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Address Line | 1499 W 1ST ST
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City | SAN PEDRO
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State | CA
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Zip | 90732-3255
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Country | US
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Telephone | 310-241-2590
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Fax |
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Provider Business Mailing Address
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Address Line | 1499 W 1ST ST
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City | SAN PEDRO
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State | CA
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Zip | 90732-3255
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Country | US
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Telephone | 310-241-2590
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QA0505X
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Taxonomy Name | Adult Medicine Physician
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License Number | 4301090843
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 207QA0505X
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Taxonomy Name | Adult Medicine Physician
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License Number | A106987
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License Number State | CA
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