Otis Optometry, LLC

Primary specialty

OptometristTaxonomy code 152W00000X

License

TO3134 Issued in MO

Legal business name

OTIS OPTOMETRY, LLC

Practice address

94 Cecil St
Camdenton, MO 65020-7057

Phone

(573) 317-9279

Fax

(888) 841-1312

NPI assigned

May 12, 2014

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Matt David Wickham, O.D.

Title

Owner

Phone

(314) 276-1228

Specialties & licenses 1

Addresses

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1399852800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1406592000000",
    "number": "1568873602",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1939 WENTZVILLE PKWY",
            "address_2": "STE 166",
            "city": "WENTZVILLE",
            "state": "MO",
            "postal_code": "633853424",
            "telephone_number": "636-812-3821",
            "fax_number": "888-841-1312"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "94 CECIL ST",
            "city": "CAMDENTON",
            "state": "MO",
            "postal_code": "650207057",
            "telephone_number": "573-317-9279",
            "fax_number": "888-841-1312"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "OTIS OPTOMETRY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-05-12",
        "last_updated": "2014-07-29",
        "status": "A",
        "authorized_official_last_name": "WICKHAM",
        "authorized_official_first_name": "MATT",
        "authorized_official_middle_name": "DAVID",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "314-276-1228",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "O.D."
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Optometrist",
            "state": "MO",
            "license": "TO3134",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Optometrist in Camdenton, MO
• Providers in Camdenton, MO by specialty
• Optometrist in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 29, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.