Provider Demographics
NPI:1154392470
Name:OTA, GORDON KIYOSHI (OD)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:KIYOSHI
Last Name:OTA
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 1:10130 WARNER AVE
Mailing Address - Street 2:SUITE J
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-1619
Mailing Address - Country:US
Mailing Address - Phone:714-965-5130
Mailing Address - Fax:
Practice Address - Street 1:10130 WARNER AVE
Practice Address - Street 2:SUITE J
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-1619
Practice Address - Country:US
Practice Address - Phone:714-965-5130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAT7549152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0075490Medicaid
CAT70206Medicare UPIN
CASD0075490Medicaid