Provider Demographics
NPI:1598752859
Name:OTTOMEYER, RICHARD VINCENT (DC)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:VINCENT
Last Name:OTTOMEYER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23315 ITASCA AVE N
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-8277
Mailing Address - Country:US
Mailing Address - Phone:651-226-8338
Mailing Address - Fax:
Practice Address - Street 1:168 LAKE ST S STE C
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-4401
Practice Address - Country:US
Practice Address - Phone:651-226-8338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1818111N00000X, 111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN513527000Medicaid
MN513527000Medicaid
MN350001213Medicare ID - Type Unspecified