Provider Demographics
NPI:1336335959
Name:BOTTJER, CAROL A (OD)
Entity type:Individual
Prefix:DR
First Name:CAROL
Middle Name:A
Last Name:BOTTJER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1640
Mailing Address - Street 2:
Mailing Address - City:CEDAR CREST
Mailing Address - State:NM
Mailing Address - Zip Code:87008-1640
Mailing Address - Country:US
Mailing Address - Phone:505-286-0300
Mailing Address - Fax:505-286-7754
Practice Address - Street 1:12220 STATE HIGHWAY 14 N
Practice Address - Street 2:SUITE 3
Practice Address - City:CEDAR CREST
Practice Address - State:NM
Practice Address - Zip Code:87008-1640
Practice Address - Country:US
Practice Address - Phone:505-286-0300
Practice Address - Fax:505-286-7754
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1668DT152W00000X
NM661152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM01259245Medicaid
NM01259245Medicaid