Provider Demographics
NPI:1013055102
Name:BOTTA, MARIVIC DAYRIT (MD)
Entity type:Individual
Prefix:
First Name:MARIVIC
Middle Name:DAYRIT
Last Name:BOTTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BEARD SAWMILL RD
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-6150
Mailing Address - Country:US
Mailing Address - Phone:203-452-8322
Mailing Address - Fax:203-452-8326
Practice Address - Street 1:15 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-1351
Practice Address - Country:US
Practice Address - Phone:203-452-8322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT045299174400000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT061319954OtherTAX ID#