Provider Demographics
NPI:1578619151
Name:CACCIOTTI, LYNETTE MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:LYNETTE
Middle Name:MARIE
Last Name:CACCIOTTI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10940 SANTA MONICA BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-4539
Mailing Address - Country:US
Mailing Address - Phone:310-966-5030
Mailing Address - Fax:310-966-9369
Practice Address - Street 1:10940 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-4539
Practice Address - Country:US
Practice Address - Phone:310-966-5030
Practice Address - Fax:310-966-9369
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7149T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGD535ZMedicare PIN
CAOP7149Medicare PIN
CA1136110001Medicare NSC