Basic Information
| Provider Information | |||||||||
| NPI: | 1962145995 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOTTEN | ||||||||
| FirstName: | MARIJO | ||||||||
| MiddleName: | LAURENE | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 32 GROVE ST | ||||||||
| Address2: | |||||||||
| City: | MAHTOMEDI | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551151630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7638075661 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 1ST ST SW | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559050002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9049538215 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2022 | ||||||||
| LastUpdateDate: | 07/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 32594 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.