Basic Information
| Provider Information | |||||||||
| NPI: | 1053762583 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOTHWELL | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | CRAIG | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | USA MEDDAC-AK ATTN: MCUC-MMD-QM (CREDENTIALS) | ||||||||
| Address2: | 1060 GAFFNEY RD | ||||||||
| City: | FT. WAINWRIGHT | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997037440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073615603 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3406 ALDER AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WAINWRIGHT | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0735312389 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2016 | ||||||||
| LastUpdateDate: | 01/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 101294 | MT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.