Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207QA0505X | Family Doctor - Adult Medicine | 4301090843 | MI |
Y | 207QA0505X | Family Doctor - Adult Medicine | A106987 | CA |
NPI | 1124227772 |
---|---|
Provider Name | Dr. Issa M Botros |
First Address | San Pedro, CA 90732-3255 |
Second Address | San Pedro, CA 90732-3255 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/07/2007 |
Last Update Date | 30/11/2021 |