Provider Demographics
NPI:1902880933
Name:BOTERO, CARLOS ALBERTO (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:ALBERTO
Last Name:BOTERO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100910
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-4548
Mailing Address - Country:US
Mailing Address - Phone:863-682-7246
Mailing Address - Fax:863-682-5566
Practice Address - Street 1:541 S FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-5228
Practice Address - Country:US
Practice Address - Phone:863-682-7246
Practice Address - Fax:863-682-5566
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-02
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME72561207L00000X, 2084A0401X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL32989OtherBCBS
FL050077125OtherRAILROAD MEDICARE
FL32989ZMedicare PIN
FL32989OtherBCBS