Healthcare Provider Details

I. General information

NPI: 1336276757
Provider Name (Legal Business Name): CORNELIUS MIETUS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 02/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 COAST VILLAGE RD
SANTA BARBARA CA
93108-2716
US

IV. Provider business mailing address

1125 COAST VILLAGE RD
SANTA BARBARA CA
93108-2716
US

V. Phone/Fax

Practice location:
  • Phone: 805-969-2020
  • Fax:
Mailing address:
  • Phone: 805-969-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number7012-T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: