Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208100000X | Physical Medicine & Rehabilitation Doctor | ME119694 | FL |
N | 2081S0010X | Sports Medicine | 29899 | KY |
N | 213ES0000X | Sports Medicine | 29899 | KY |
NPI | 1134252349 |
---|---|
Provider Name | Dr. Bryan Keith Botner |
First Address | Winter Park, FL 32789-2127 |
Second Address | Winter Park, FL 32789-2127 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/03/2007 |
Last Update Date | 04/03/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
43105 | ANTHEM BC AND BS (01) | KY |
F61950 | (02) |