Provider Demographics
NPI:1336175892
Name:BOTTOLFSON, DIANE M (MD)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:BOTTOLFSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2501 W 22ND ST
Mailing Address - Street 2:PO BOX 5046
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-1305
Mailing Address - Country:US
Mailing Address - Phone:605-333-6859
Mailing Address - Fax:605-373-4120
Practice Address - Street 1:2501 W 22ND ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1305
Practice Address - Country:US
Practice Address - Phone:605-333-6859
Practice Address - Fax:605-373-4120
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SD4480207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology