Provider Demographics
NPI:1609844091
Name:SMALL, JOHN LUCAS (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LUCAS
Last Name:SMALL
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 1:2235 CHAPALA ST
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93105-3906
Mailing Address - Country:US
Mailing Address - Phone:805-921-3023
Mailing Address - Fax:
Practice Address - Street 1:5434 CARPINTERIA AVE
Practice Address - Street 2:
Practice Address - City:CARPINTERIA
Practice Address - State:CA
Practice Address - Zip Code:93013-1423
Practice Address - Country:US
Practice Address - Phone:805-684-5476
Practice Address - Fax:805-684-5477
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12435T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU97278Medicare UPIN
CAOP12435Medicare ID - Type Unspecified