Provider Demographics
NPI:1811981418
Name:OTTO, JOHN LEIGH (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LEIGH
Last Name:OTTO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:701 N 182ND ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-4430
Mailing Address - Country:US
Mailing Address - Phone:206-542-7406
Mailing Address - Fax:206-546-2266
Practice Address - Street 1:701 N 182ND ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98133-4430
Practice Address - Country:US
Practice Address - Phone:206-542-7406
Practice Address - Fax:206-546-2266
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1604152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2130037Medicaid
WATO3077Medicare UPIN
WA2130037Medicaid