Basic Information
| Provider Information | |||||||||
| NPI: | 1962459982 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOTHWELL | ||||||||
| FirstName: | MARCELLA | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3860 CALLE FORTUNADA | ||||||||
| Address2: | STE #210 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921234802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8583096303 | ||||||||
| FaxNumber: | 8583096301 | ||||||||
| Practice Location | |||||||||
| Address1: | 3030 CHILDRENS WAY | ||||||||
| Address2: | SUITE 402 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921234232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8583097701 | ||||||||
| FaxNumber: | 8589668038 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 11/16/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YP0228X | G87904 | CA | Y | Allopathic & Osteopathic Physicians | Otolaryngology | Pediatric Otolaryngology | 207Y00000X | G87904 | CA | N | Allopathic & Osteopathic Physicians | Otolaryngology |
No ID Information.