Provider Demographics
NPI:1306066006
Name:LOWELL J. BOOTH OPTOMETRIST
Entity type:Organization
Organization Name:LOWELL J. BOOTH OPTOMETRIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING CLERK
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOHANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-838-3210
Mailing Address - Street 1:1102 IRVINE BLVD
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3529
Mailing Address - Country:US
Mailing Address - Phone:714-838-3210
Mailing Address - Fax:714-838-5702
Practice Address - Street 1:1102 IRVINE BLVD
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3529
Practice Address - Country:US
Practice Address - Phone:714-838-3210
Practice Address - Fax:714-838-5702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT-4984-TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0049840Medicaid
CASD0049840Medicaid
CA0833860001Medicare NSC
CAOP4984Medicare PIN