Provider Demographics
NPI:1093909152
Name:ROGER A OTTO O D P A
Entity Type:Organization
Organization Name:ROGER A OTTO O D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-294-9711
Mailing Address - Street 1:1444 KENNEDY DR
Mailing Address - Street 2:
Mailing Address - City:KEY WEST
Mailing Address - State:FL
Mailing Address - Zip Code:33040-4008
Mailing Address - Country:US
Mailing Address - Phone:305-294-9711
Mailing Address - Fax:305-294-8307
Practice Address - Street 1:1444 KENNEDY DR
Practice Address - Street 2:
Practice Address - City:KEY WEST
Practice Address - State:FL
Practice Address - Zip Code:33040-4008
Practice Address - Country:US
Practice Address - Phone:305-294-9711
Practice Address - Fax:305-294-8307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-31
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1436152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL084019000Medicaid
FL084967700Medicaid
FL084967700Medicaid
FL19315ZMedicare PIN
FLT93770Medicare UPIN
FL084019000Medicaid
FL19717AMedicare PIN