Provider Demographics
NPI:1164543609
Name:OTTO, JOSEPH V (OD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:V
Last Name:OTTO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7519 PRESIDENTIAL LN
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-2629
Mailing Address - Country:US
Mailing Address - Phone:703-257-7587
Mailing Address - Fax:
Practice Address - Street 1:7519 PRESIDENTIAL LN
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-2629
Practice Address - Country:US
Practice Address - Phone:703-257-7587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2010-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001835152W00000X, 152WC0802X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision