Provider Demographics
NPI:1265771042
Name:OTTOSON, KEVIN L (LDO)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:L
Last Name:OTTOSON
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14243 POWELL RD
Mailing Address - Street 2:UNIT 201
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-8100
Mailing Address - Country:US
Mailing Address - Phone:352-600-2990
Mailing Address - Fax:
Practice Address - Street 1:14243 POWELL RD
Practice Address - Street 2:UNIT 201
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34609-8100
Practice Address - Country:US
Practice Address - Phone:352-600-2990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-13
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO-5151156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician