Healthcare Provider Details

I. General information

NPI: 1750487898
Provider Name (Legal Business Name): LARRY EDWARD OTWELL OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 02/27/2023
Certification Date: 02/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72840 CA-111 S SUITE F201
PALM DESERT CA
92260
US

IV. Provider business mailing address

977 BEL AIR DR
PALM SPRINGS CA
92264-0663
US

V. Phone/Fax

Practice location:
  • Phone: 760-848-0040
  • Fax:
Mailing address:
  • Phone: 206-619-1230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1735
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: