Provider Demographics
NPI:1770647521
Name:OTTO, KENNETH LEE (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LEE
Last Name:OTTO
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 1:308 E NORTHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-2163
Mailing Address - Country:US
Mailing Address - Phone:920-739-6800
Mailing Address - Fax:920-739-3999
Practice Address - Street 1:308 E NORTHLAND AVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-2163
Practice Address - Country:US
Practice Address - Phone:920-739-6800
Practice Address - Fax:920-739-3999
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3082-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38976800Medicaid
WI000035755Medicare PIN
WI35755Medicare ID - Type UnspecifiedRENDERING PROVIDER ID