Provider Demographics
NPI:1497802698
Name:LOVELACE, JOHN CULLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CULLEN
Last Name:LOVELACE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9112
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75404-9112
Mailing Address - Country:US
Mailing Address - Phone:903-454-2763
Mailing Address - Fax:903-454-2733
Practice Address - Street 1:8709 WESLEY ST
Practice Address - Street 2:STE. F
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75402-3828
Practice Address - Country:US
Practice Address - Phone:903-454-2763
Practice Address - Fax:903-454-2733
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3066TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0932204-02Medicaid
TXT14484Medicare UPIN
TX0932204-02Medicaid