MEDICARE: MARCELLA R. BOTHWELL MD

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	207YP0228X	Pediatric Otolaryngology Physician	G87904	CA
2	207Y00000X	Otolaryngology Physician	G87904	CA

General Provider Information

NPI Number	:	1962459982
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARCELLA R. BOTHWELL MD

Provider Business Mailing Address
First Line	:	3860 CALLE FORTUNADA
Second Line	:	STE #210
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-4802
Country	:	US
Telephone Number	:	858-309-6303
Fax Number	:	858-309-6301

Provider Business Practice Location Address
First Line	:	3030 CHILDRENS WAY
Second Line	:	SUITE 402
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-4232
Country	:	US
Telephone Number	:	858-309-7701
Fax Number	:	858-966-8038

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

Provider Enumeration Date	:	05/27/2006
Last Update Date	:	11/16/2011

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