| Entity Name: | ROGER A. OTTO, O.D., P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 20 Jun 1991 (34 years ago) |
| Document Number: | S61885 |
| FEI/EIN Number | 650273719 |
| Mail Address: | 3992 Sweet Magnolia Dr, Gainesville, GA, 30504, US |
| Address: | 1444 KENNEDY DR., KEY WEST, FL, 33040 |
| ZIP code: | 33040 |
| County: | Monroe |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1093909152 | 2007-08-31 | 2008-04-28 | 1444 KENNEDY DR, KEY WEST, FL, 330404008, US | 1444 KENNEDY DR, KEY WEST, FL, 330404008, US | |||||||||||||||||||||||||||||||
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| Phone | +1 305-294-9711 |
| Fax | 3052948307 |
Authorized person
| Name | TAMMY FORD |
| Role | OFFICE MANAGER |
| Phone | 3052949711 |
Taxonomy
| Taxonomy Code | 152W00000X - Optometrist |
| License Number | OPC1436 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 084019000 |
| State | FL |
| Issuer | MEDICAID |
| Number | 084967700 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| otto roger | Agent | 1444 KENNEDY DR., KEY WEST, FL, 33040 |
| Name | Role | Address |
|---|---|---|
| OTTO, ROGER A. | President | 1444 KENNEDY DRIVE, KEY WEST, FL, 33040 |
| Name | Role | Address |
|---|---|---|
| OTTO CORY | Vice President | 1444 KENNEDY DRIVE, KEY WEST, FL, 33040 |
Date of last update: 02 Jan 2025
Sources: Florida Department of State
