Provider Demographics
NPI:1598723587
Name:PACK, JOHN C (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:PACK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:374 E H ST
Mailing Address - Street 2:STE 1708
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-7484
Mailing Address - Country:US
Mailing Address - Phone:619-425-7990
Mailing Address - Fax:619-425-7992
Practice Address - Street 1:374 E H ST
Practice Address - Street 2:STE 1708
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-7484
Practice Address - Country:US
Practice Address - Phone:619-425-7990
Practice Address - Fax:619-425-7992
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9684T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
200547724OtherTAX ID
912870OtherIMED
CASD0096840Medicaid
U29682Medicare UPIN
200547724OtherTAX ID
WOP9684EMedicare PIN