Provider Demographics
NPI:1063614337
Name:BOTONE, ZACHARY Q (MD)
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:Q
Last Name:BOTONE
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 1:2740 N. HWY 360
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050
Mailing Address - Country:US
Mailing Address - Phone:972-606-8300
Mailing Address - Fax:972-606-4940
Practice Address - Street 1:2740 N. HWY 360
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75050
Practice Address - Country:US
Practice Address - Phone:972-606-8300
Practice Address - Fax:972-606-4940
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2011-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN3510207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX215868501Medicaid
BP1-0026105OtherINSTITUTIONAL PERMIT
TX8F5134OtherBCBSTX
TX215868501Medicaid