Provider Demographics
NPI:1154996072
Name:SILOAM MEDICAL
Entity type:Organization
Organization Name:SILOAM MEDICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BOTTARO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:813-330-0574
Mailing Address - Street 1:15123 OGDEN LOOP
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-4633
Mailing Address - Country:US
Mailing Address - Phone:813-330-0574
Mailing Address - Fax:
Practice Address - Street 1:15123 OGDEN LOOP
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:FL
Practice Address - Zip Code:33556-4633
Practice Address - Country:US
Practice Address - Phone:860-268-6617
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-24
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma SpecialistGroup - Multi-Specialty
No207WX0120XAllopathic & Osteopathic PhysiciansOphthalmologyCornea and External Diseases SpecialistGroup - Multi-Specialty
No207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108311400Medicaid