Provider Demographics
NPI:1720256480
Name:ANTOINETTE L BOTTI OD
Entity type:Organization
Organization Name:ANTOINETTE L BOTTI OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTOINETTE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOTTI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:814-445-6395
Mailing Address - Street 1:PO BOX 942
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:PA
Mailing Address - Zip Code:15501-0942
Mailing Address - Country:US
Mailing Address - Phone:814-445-6395
Mailing Address - Fax:814-444-1292
Practice Address - Street 1:134 WEST MAIN ST
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:PA
Practice Address - Zip Code:15501
Practice Address - Country:US
Practice Address - Phone:814-445-6395
Practice Address - Fax:814-444-1292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000984152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0615830001OtherDMERC
PABO129484Medicare PIN
PA0615830001Medicare NSC