Provider Demographics
NPI:1164403838
Name:OTTO, KENNETH ALAN JR (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ALAN
Last Name:OTTO
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:1266 E SHERMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1847
Mailing Address - Country:US
Mailing Address - Phone:231-739-9009
Mailing Address - Fax:231-733-0566
Practice Address - Street 1:1266 E SHERMAN BLVD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1847
Practice Address - Country:US
Practice Address - Phone:231-739-9009
Practice Address - Fax:231-733-0566
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2020-10-12
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Provider Licenses
StateLicense IDTaxonomies
MI4301403805207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C58076Medicare UPIN
ON13910003Medicare ID - Type Unspecified