Basic Information
| Provider Information | |||||||||
| NPI: | 1518050079 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOTDORF | ||||||||
| FirstName: | JOSHUA | ||||||||
| MiddleName: | STEVENSON | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4439 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772104439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137922991 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1515 HOLCOMBE BLVD | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770304009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137926161 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 07/01/2019 | ||||||||
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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 | 207R00000X | T2006017752 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | 107079 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RC0200X | 56817 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RC0200X | 2011014544 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RN0300X | 2011014544 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RC0200X | R1504 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8KM370 | 01 | TX | BCBS | OTHER | 393432501 | 05 | TX | MEDICAID |