Healthcare Provider Details

I. General information

NPI: 1033187075
Provider Name (Legal Business Name): PETER BOTTAR D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 10/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 OAK KNOLL DR.
HUBBARD OH
44425-2198
US

IV. Provider business mailing address

50 OAK KNOLL DR.
HUBBARD OH
44425-2198
US

V. Phone/Fax

Practice location:
  • Phone: 330-534-9711
  • Fax: 330-534-0502
Mailing address:
  • Phone: 330-534-9711
  • Fax: 330-534-0502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2996
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: