Provider Demographics
NPI:1205112893
Name:KOTS, GARY S (OD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:S
Last Name:KOTS
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:PO BOX 1201
Mailing Address - Street 2:
Mailing Address - City:PINE RIDGE
Mailing Address - State:SD
Mailing Address - Zip Code:57770-1201
Mailing Address - Country:US
Mailing Address - Phone:605-867-3224
Mailing Address - Fax:
Practice Address - Street 1:400 SOLDIER CREEK DR
Practice Address - Street 2:
Practice Address - City:ROSEBUD
Practice Address - State:SD
Practice Address - Zip Code:57570-8502
Practice Address - Country:US
Practice Address - Phone:605-747-0481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-26
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003171152W00000X, 152WL0500X, 152WP0200X, 152WV0400X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy