Healthcare Provider Details

I. General information

NPI: 1154996072
Provider Name (Legal Business Name): SILOAM MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2021
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15123 OGDEN LOOP
ODESSA FL
33556-4633
US

IV. Provider business mailing address

15123 OGDEN LOOP
ODESSA FL
33556-4633
US

V. Phone/Fax

Practice location:
  • Phone: 860-268-6617
  • Fax:
Mailing address:
  • Phone: 813-330-0574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207WX0120X
TaxonomyCornea and External Diseases Specialist Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: NICHOLAS BOTTARO
Title or Position: OWNER
Credential: DO
Phone: 813-330-0574