Provider Demographics
NPI:1528254026
Name:BOTWIN, JONATHAN DANIEL (OD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:DANIEL
Last Name:BOTWIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1826 SUN MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4509
Mailing Address - Country:US
Mailing Address - Phone:505-986-8131
Mailing Address - Fax:
Practice Address - Street 1:444 SAINT MICHAELS DR STE A
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7674
Practice Address - Country:US
Practice Address - Phone:505-954-4442
Practice Address - Fax:505-954-4448
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-18
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM581152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist