Provider Demographics
NPI:1699758979
Name:BOTERO, JORGE M (MD)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:M
Last Name:BOTERO
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 1:360 MERRIMACK ST
Mailing Address - Street 2:BLDG 9, ENTRANCE I
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01843-1740
Mailing Address - Country:US
Mailing Address - Phone:978-688-6182
Mailing Address - Fax:978-689-0731
Practice Address - Street 1:360 MERRIMACK ST
Practice Address - Street 2:BLDG 9, ENTRANCE I
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01843-1740
Practice Address - Country:US
Practice Address - Phone:978-688-6182
Practice Address - Fax:978-689-0731
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA76765207P00000X, 207W00000X
NH9469207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3080859Medicaid
MA110052237AMedicaid
MA110052237AMedicaid