Basic Information
| Provider Information | |||||||||
| NPI: | 1124018114 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOTIMER | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25455 BARTON RD | ||||||||
| Address2: | STE 102B | ||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923543128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095582808 | ||||||||
| FaxNumber: | 9095585599 | ||||||||
| Practice Location | |||||||||
| Address1: | 25455 BARTON RD | ||||||||
| Address2: | STE 102B | ||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923543128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095582808 | ||||||||
| FaxNumber: | 9095585599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2005 | ||||||||
| LastUpdateDate: | 02/18/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | M4699 | ID | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 000010147414 | 01 | ID | BLUE SHIELD | OTHER | 000010005946 | 01 | ID | BLUE SHIELD | OTHER | B0891 | 01 | ID | BLUE CROSS | OTHER | 200011749 | 01 | ID | RAILROAD MEDICARE | OTHER | 46995 | 01 | ID | BLUE CROSS | OTHER | 002363100 | 05 | ID | MEDICAID | 33555 | 01 | ID | BLUE SHIELD | OTHER | 000010005947 | 01 | ID | BLUE SHIELD | OTHER |