Provider Demographics
NPI:1174611107
Name:BOTTARI, BRENDAN (MD)
Entity type:Individual
Prefix:
First Name:BRENDAN
Middle Name:
Last Name:BOTTARI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 SOTOYOME ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4823
Mailing Address - Country:US
Mailing Address - Phone:707-546-4062
Mailing Address - Fax:707-578-6258
Practice Address - Street 1:121 SOTOYOME ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4823
Practice Address - Country:US
Practice Address - Phone:707-546-4062
Practice Address - Fax:707-578-6258
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA819222085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Not Answered2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A891220Medicaid
00A891220Medicare ID - Type Unspecified
CA00A891220Medicaid