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General NPI Number Information
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NPI Number | 1134252349
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Entity Type | Individual
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Provider Name | BRYAN KEITH BOTNER M.D.
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Gender | Male
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Dates
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Enumeration Date | 03/14/2007
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Last Update Date | 03/04/2019
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Provider Practice Location Address
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Address Line | 1801 LEE RD STE 165
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City | WINTER PARK
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State | FL
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Zip | 32789-2127
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Country | US
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Telephone | 407-922-7691
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Fax | 407-975-0407
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Provider Business Mailing Address
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Address Line | 1801 LEE RD STE 165
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City | WINTER PARK
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State | FL
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Zip | 32789-2127
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Country | US
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Telephone | 407-922-7691
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Fax | 407-975-0407
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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 | 2081S0010X
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Taxonomy Name | Sports Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | 29899
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | ME119694
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License Number State | FL
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