Provider Demographics
NPI:1942824503
Name:KROCHMAL, JOHN JACOB IV (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JACOB
Last Name:KROCHMAL
Suffix:IV
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 1:174 SIESTA AVE
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-1816
Mailing Address - Country:US
Mailing Address - Phone:805-231-0877
Mailing Address - Fax:
Practice Address - Street 1:1A S MILPAS ST
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93103-3305
Practice Address - Country:US
Practice Address - Phone:805-231-0877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-29
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA34564152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program