Healthcare Provider Details

I. General information

NPI: 1730409160
Provider Name (Legal Business Name): JOSEPH V. OTTO, O.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2010
Last Update Date: 06/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7519 PRESIDENTIAL LN
MANASSAS VA
20109-2629
US

IV. Provider business mailing address

7519 PRESIDENTIAL LN
MANASSAS VA
20109-2629
US

V. Phone/Fax

Practice location:
  • Phone: 703-257-7587
  • Fax:
Mailing address:
  • Phone: 703-257-7587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618001835
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number0618001835
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number0618001835
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number0618001835
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number0618001835
License Number StateVA

VIII. Authorized Official

Name: DR. JOSEPH OTTO
Title or Position: OWNER
Credential: OD
Phone: 703-257-7587