Provider Demographics
NPI:1619028842
Name:SERVICE, LINCOLN ANDRUS JR (OD)
Entity Type:Individual
Prefix:
First Name:LINCOLN
Middle Name:ANDRUS
Last Name:SERVICE
Suffix:JR
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 1:752 MADRID ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94112-3547
Mailing Address - Country:US
Mailing Address - Phone:415-452-8225
Mailing Address - Fax:
Practice Address - Street 1:3500 SISK RD
Practice Address - Street 2:BEST PLAZA STE E
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-0550
Practice Address - Country:US
Practice Address - Phone:209-545-4457
Practice Address - Fax:209-545-2416
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7573152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASDO075730Medicare ID - Type Unspecified
CAT70209Medicare UPIN