Provider Demographics
NPI:1831148675
Name:OTTO, ROGER A (OD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:A
Last Name:OTTO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1444 KENNEDY DR
Mailing Address - Street 2:
Mailing Address - City:KEY WEST
Mailing Address - State:FL
Mailing Address - Zip Code:33040-4008
Mailing Address - Country:US
Mailing Address - Phone:305-294-9711
Mailing Address - Fax:305-294-2456
Practice Address - Street 1:1444 KENNEDY DR
Practice Address - Street 2:
Practice Address - City:KEY WEST
Practice Address - State:FL
Practice Address - Zip Code:33040-4008
Practice Address - Country:US
Practice Address - Phone:305-294-9711
Practice Address - Fax:305-294-2456
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1436152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4354230001OtherDMEC MEDICARE
FL4354230001OtherDMEC MEDICARE