Healthcare Provider Details

I. General information

NPI: 1568643724
Provider Name (Legal Business Name): PETER BOTTAR DO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2007
Last Update Date: 11/16/2007
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:
Mailing address:
  • Phone: 330-534-9711
  • Fax:

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: PETER BOTTAR
Title or Position: PRESIDENT
Credential: DO
Phone: 330-534-9711