Provider Demographics
NPI:1215908421
Name:BOTARDO, ELENA GINES (MD)
Entity type:Individual
Prefix:
First Name:ELENA
Middle Name:GINES
Last Name:BOTARDO
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 1:1381 S PATRICK DR
Mailing Address - Street 2:
Mailing Address - City:PATRICK AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32925-3606
Mailing Address - Country:US
Mailing Address - Phone:321-494-8241
Mailing Address - Fax:
Practice Address - Street 1:1381 S PATRICK DR
Practice Address - Street 2:
Practice Address - City:PATRICK AFB
Practice Address - State:FL
Practice Address - Zip Code:32925
Practice Address - Country:US
Practice Address - Phone:321-494-8241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME66902207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F89984Medicare UPIN
FL25933YMedicare PIN
FL376968200Medicaid
FL0471260004Medicare NSC