Provider Demographics
NPI:1760685622
Name:BOTVINOV, MIKHAIL A (DO)
Entity type:Individual
Prefix:DR
First Name:MIKHAIL
Middle Name:A
Last Name:BOTVINOV
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:23 ROBYN CT
Mailing Address - Street 2:
Mailing Address - City:EMERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07630-1464
Mailing Address - Country:US
Mailing Address - Phone:201-693-2653
Mailing Address - Fax:201-778-5399
Practice Address - Street 1:260 OLD HOOK ROAD,
Practice Address - Street 2:SUITE 303A
Practice Address - City:WESTWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07675-3123
Practice Address - Country:US
Practice Address - Phone:201-778-5344
Practice Address - Fax:201-778-5399
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB08725300208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery