MEDICARE: DR. JOHN C PACK OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	9684T	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	200547724	OTHER	TAX ID
2	912870	OTHER	IMED
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598723587
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN C PACK OD

Provider Business Mailing Address
First Line	:	374 E H ST
Second Line	:	STE 1708
City	:	CHULA VISTA
State	:	CA
Zip	:	91910-7484
Country	:	US
Telephone Number	:	619-425-7990
Fax Number	:	619-425-7992

Provider Business Practice Location Address
First Line	:	374 E H ST
Second Line	:	STE 1708
City	:	CHULA VISTA
State	:	CA
Zip	:	91910-7484
Country	:	US
Telephone Number	:	619-425-7990
Fax Number	:	619-425-7992

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2006
Last Update Date	:	06/18/2008

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Directions to “ DR. JOHN C PACK OD” Practice Location

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