Provider Demographics
NPI:1568873602
Name:OTIS OPTOMETRY, LLC
Entity Type:Organization
Organization Name:OTIS OPTOMETRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATT
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:WICKHAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:314-276-1228
Mailing Address - Street 1:1939 WENTZVILLE PKWY
Mailing Address - Street 2:STE 166
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-3424
Mailing Address - Country:US
Mailing Address - Phone:636-812-3821
Mailing Address - Fax:888-841-1312
Practice Address - Street 1:94 CECIL ST
Practice Address - Street 2:
Practice Address - City:CAMDENTON
Practice Address - State:MO
Practice Address - Zip Code:65020-7057
Practice Address - Country:US
Practice Address - Phone:573-317-9279
Practice Address - Fax:888-841-1312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-12
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO3134152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty