Provider Demographics
NPI:1134235799
Name:OTTOMEYER, RAYMOND JAMES III (DC)
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:JAMES
Last Name:OTTOMEYER
Suffix:III
Gender:M
Credentials:DC
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:199 FRONTIER PARK DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-3963
Mailing Address - Country:US
Mailing Address - Phone:636-379-5934
Mailing Address - Fax:636-410-3323
Practice Address - Street 1:2011 HIGHWAY K
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-3965
Practice Address - Country:US
Practice Address - Phone:636-379-5934
Practice Address - Fax:636-980-1059
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO006182111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO230079324Medicaid
MO5064408OtherAETNA PROVIDER NUMBER
MO19387OtherBLUECROSS PROVIDER NUMBER
MO248480OtherHEALTHLINK PROVIDER NUMBE
MO000031923Medicare ID - Type UnspecifiedID NUMBER
MO431864893OtherFEDERAL TAX ID NUMBER
MO19387OtherBLUECROSS PROVIDER NUMBER