Healthcare Provider Details

I. General information

NPI: 1750361424
Provider Name (Legal Business Name): LOWELL JOHN BOOTH OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 01/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 IRVINE BLVD
TUSTIN CA
92780-3529
US

IV. Provider business mailing address

1102 IRVINE BLVD
TUSTIN CA
92780-3529
US

V. Phone/Fax

Practice location:
  • Phone: 714-838-3210
  • Fax: 714-838-5702
Mailing address:
  • Phone: 714-838-3210
  • Fax: 714-838-5702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT4984 TPL
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: