Provider Demographics
NPI:1902996309
Name:BOTERO, ANDRES (MD)
Entity Type:Individual
Prefix:
First Name:ANDRES
Middle Name:
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 1:500 OLD YORK RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:JENKINTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19046-2852
Mailing Address - Country:US
Mailing Address - Phone:215-886-0174
Mailing Address - Fax:215-886-9217
Practice Address - Street 1:500 OLD YORK RD
Practice Address - Street 2:SUITE 203
Practice Address - City:JENKINTOWN
Practice Address - State:PA
Practice Address - Zip Code:19046-2852
Practice Address - Country:US
Practice Address - Phone:215-886-0174
Practice Address - Fax:215-886-9217
Is Sole Proprietor?:No
Enumeration Date:2006-10-14
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD429670207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA106640Medicare PIN