Provider Demographics
NPI:1497378525
Name:MOTACEK, AARON LARRY (OD)
Entity Type:Individual
Prefix:
First Name:AARON
Middle Name:LARRY
Last Name:MOTACEK
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 1:4906 28TH AVE S APT 404
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-9020
Mailing Address - Country:US
Mailing Address - Phone:701-320-2738
Mailing Address - Fax:
Practice Address - Street 1:1300 GATEWAY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3509
Practice Address - Country:US
Practice Address - Phone:701-235-0280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-23
Last Update Date:2020-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND773152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist