Provider Demographics
NPI:1336276757
Name:MIETUS, CORNELIUS (OD)
Entity Type:Individual
Prefix:DR
First Name:CORNELIUS
Middle Name:
Last Name:MIETUS
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 1:1125 COAST VILLAGE RD
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93108-2716
Mailing Address - Country:US
Mailing Address - Phone:805-969-2020
Mailing Address - Fax:
Practice Address - Street 1:1125 COAST VILLAGE RD
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93108-2716
Practice Address - Country:US
Practice Address - Phone:805-969-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7012-T152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB204914Medicare PIN