Provider Demographics
NPI:1730936030
Name:OTA, KYLE
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:OTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 CASTILLON WAY
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95119-1502
Mailing Address - Country:US
Mailing Address - Phone:408-239-7232
Mailing Address - Fax:
Practice Address - Street 1:3081B CLAIREMONT DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-6802
Practice Address - Country:US
Practice Address - Phone:619-275-1175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-03
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89474183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist