Basic Information
| Provider Information | |||||||||
| NPI: | 1396193611 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOTTARO | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O., M.H.S.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13904 N DALE MABRY HWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336182446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139082020 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 13904 N DALE MABRY HWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336182446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139082020 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2016 | ||||||||
| LastUpdateDate: | 06/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS14898 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207W00000X | OS14898 | FL | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.