Provider Demographics
NPI:1316967714
Name:BOTASH, ANN SUTERA (MD)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:SUTERA
Last Name:BOTASH
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 1:90 PRESIDENTIAL PLZ
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-2240
Mailing Address - Country:US
Mailing Address - Phone:315-464-4357
Mailing Address - Fax:315-464-2030
Practice Address - Street 1:90 PRESIDENTIAL PLZ
Practice Address - Street 2:3RD FLOOR
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-2240
Practice Address - Country:US
Practice Address - Phone:315-464-4357
Practice Address - Fax:315-464-2030
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2010-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY170003208000000X, 2080C0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080C0008XAllopathic & Osteopathic PhysiciansPediatricsChild Abuse Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01185377Medicaid
NY01185377Medicaid
NYJ400009653Medicare PIN