Provider Demographics
NPI:1164406302
Name:MICHAEL W OTTATI, JR., O.D. INC
Entity Type:Organization
Organization Name:MICHAEL W OTTATI, JR., O.D. INC
Other - Org Name:DIABLO VALLEY OPTOMETRIC GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:OTTATI
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:925-757-0450
Mailing Address - Street 1:3700 SUNSET LN
Mailing Address - Street 2:SUITE 4
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-6199
Mailing Address - Country:US
Mailing Address - Phone:925-757-0450
Mailing Address - Fax:925-757-0266
Practice Address - Street 1:3700 SUNSET LN
Practice Address - Street 2:SUITE 4
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-6199
Practice Address - Country:US
Practice Address - Phone:925-757-0450
Practice Address - Fax:925-757-0266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-01
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11082TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ24116ZMedicare ID - Type UnspecifiedGROUP
CASDO110821Medicare ID - Type Unspecified
U72640Medicare UPIN