Provider Demographics
NPI:1538385604
Name:DR. MERAB BOTER MEDICAL, P.C.
Entity type:Organization
Organization Name:DR. MERAB BOTER MEDICAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MERAB
Authorized Official - Middle Name:
Authorized Official - Last Name:BOTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-238-1555
Mailing Address - Street 1:2177 65TH ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204
Mailing Address - Country:US
Mailing Address - Phone:718-238-1555
Mailing Address - Fax:718-748-3666
Practice Address - Street 1:2177 65TH ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204
Practice Address - Country:US
Practice Address - Phone:718-238-1555
Practice Address - Fax:718-748-3666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY173014208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01069218Medicaid
NYW49851Medicare PIN
NYA60867Medicare UPIN