Provider Demographics
NPI:1790832996
Name:HOMUTH, ROBERT MORGAN (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MORGAN
Last Name:HOMUTH
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 1:29315 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92532-2212
Mailing Address - Country:US
Mailing Address - Phone:951-253-6043
Mailing Address - Fax:951-253-6044
Practice Address - Street 1:29315 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92532-2212
Practice Address - Country:US
Practice Address - Phone:951-253-6043
Practice Address - Fax:951-253-6044
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 6458 T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU36758Medicare UPIN