Healthcare Provider Details

I. General information

NPI: 1346249752
Provider Name (Legal Business Name): FLETCHER THOMAS OTT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 HIGHWAY 61
FESTUS MO
63028-4141
US

IV. Provider business mailing address

22 ALGONQUIN LN
SAINT LOUIS MO
63119-3502
US

V. Phone/Fax

Practice location:
  • Phone: 636-937-8855
  • Fax: 636-937-3751
Mailing address:
  • Phone: 314-961-3088
  • Fax: 636-937-2742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number30268
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: