Healthcare Provider Details

I. General information

NPI: 1396193611
Provider Name (Legal Business Name): NICHOLAS BOTTARO D.O., M.H.S.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2016
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
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:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License NumberOS14898
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberOS14898
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License NumberOS14898
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207WX0120X
TaxonomyCornea and External Diseases Specialist Physician
License NumberOS14898
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: