Provider Demographics
NPI:1033114814
Name:SPAETH, JOHN CHARLES (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CHARLES
Last Name:SPAETH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4945 YORBA RANCH RD
Mailing Address - Street 2:STE E
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92887-2553
Mailing Address - Country:US
Mailing Address - Phone:714-692-2063
Mailing Address - Fax:714-695-9384
Practice Address - Street 1:4945 YORBA RANCH RD
Practice Address - Street 2:STE E
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92887-2553
Practice Address - Country:US
Practice Address - Phone:714-692-2063
Practice Address - Fax:714-695-9384
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-17
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5602T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOP5602AMedicare ID - Type Unspecified
CAT70048Medicare UPIN