MEDICARE: DR. RAVI BOTLA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0100X	Gastroenterology Physician	J7912	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	930072561	OTHER	TX	MEDICARE - RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	87500S	OTHER	TX	BC/BS

General Provider Information

NPI Number	:	1366540544
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RAVI BOTLA M.D.

Provider Business Mailing Address
First Line	:	PO BOX 75235
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75235-0629
Country	:	US
Telephone Number	:	214-424-2200
Fax Number	:	214-231-2159

Provider Business Practice Location Address
First Line	:	621 CAMDEN STREET
Second Line	:	SUITE 202
City	:	SAN ANTONIO
State	:	TX
Zip	:	78215-1639
Country	:	US
Telephone Number	:	210-253-3422
Fax Number	:	210-227-9833

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	02/22/2017

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Directions to “ DR. RAVI BOTLA M.D.” Practice Location

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