Provider Demographics
NPI:1689645046
Name:CULLINANE, JACQUELINE MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:MARIE
Last Name:CULLINANE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:22741 LAMBERT ST STE 1601
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-1617
Mailing Address - Country:US
Mailing Address - Phone:949-581-6880
Mailing Address - Fax:949-581-1341
Practice Address - Street 1:22741 LAMBERT ST STE 1601
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-1617
Practice Address - Country:US
Practice Address - Phone:949-581-6880
Practice Address - Fax:949-581-1341
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10306TPG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWOP10306AMedicare PIN
CAU81042Medicare UPIN