Provider Demographics
NPI:1558308817
Name:OTTESON, GUY G (OD)
Entity Type:Individual
Prefix:
First Name:GUY
Middle Name:G
Last Name:OTTESON
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 1:200 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-5675
Mailing Address - Country:US
Mailing Address - Phone:701-222-3937
Mailing Address - Fax:701-222-8805
Practice Address - Street 1:200 S 5TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-5675
Practice Address - Country:US
Practice Address - Phone:701-222-3937
Practice Address - Fax:701-222-8805
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND398152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1455095Medicaid
ND11171OtherBCBS
ND60258Medicaid
410018233OtherRAILROAD MEDICARE ID
MT484263Medicaid
488241044247OtherPREFERRED ONE
ND0398OtherEYEMED
20276OtherSIOUX VALLEY HEALTH PLAN
800398OtherNDVSI
22-03329OtherMEDICA
SD9202660Medicaid
ND200OtherVISION BENEFIT OF AMERICA
ND11171OtherBCBS
T66922Medicare UPIN