Provider Demographics
NPI:1538503222
Name:OTTO, AUDREY THOMPSON (OD)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:THOMPSON
Last Name:OTTO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:THOMPSON
Other - Last Name:OTTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14994 W MAIN ST BLDG B
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39339-2616
Mailing Address - Country:US
Mailing Address - Phone:662-773-3494
Mailing Address - Fax:662-779-4030
Practice Address - Street 1:5002 HIGHWAY 39 N
Practice Address - Street 2:BUILDING B
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-1078
Practice Address - Country:US
Practice Address - Phone:601-483-7331
Practice Address - Fax:601-483-3721
Is Sole Proprietor?:No
Enumeration Date:2013-04-24
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS897152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07608766Medicaid
MS353890ZHAMMedicare PIN