Healthcare Provider Details

I. General information

NPI: 1669496469
Provider Name (Legal Business Name): THOMAS SAL BOTTIGLIERI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 03/21/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 GRAND AVE STE 101
ENGLEWOOD NJ
07631-4968
US

IV. Provider business mailing address

622 W 168TH ST PH 111130
NEW YORK NY
10032-3720
US

V. Phone/Fax

Practice location:
  • Phone: 201-569-4445
  • Fax: 212-304-7050
Mailing address:
  • Phone: 212-305-9137
  • Fax: 212-304-7050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number25MB07982100
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number237430
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: