Provider Demographics
NPI:1326116930
Name:OTT, KENDRA I (OD)
Entity Type:Individual
Prefix:DR
First Name:KENDRA
Middle Name:I
Last Name:OTT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 N ELSIE AVE
Mailing Address - Street 2:
Mailing Address - City:TEA
Mailing Address - State:SD
Mailing Address - Zip Code:57064-2162
Mailing Address - Country:US
Mailing Address - Phone:605-498-0005
Mailing Address - Fax:
Practice Address - Street 1:2414 S LOUISE AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-4318
Practice Address - Country:US
Practice Address - Phone:605-362-9255
Practice Address - Fax:605-361-0502
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD601152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS102380Medicare PIN