Provider Demographics
NPI:1720256993
Name:JOHN R PREWETT, OD INC
Entity Type:Organization
Organization Name:JOHN R PREWETT, OD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RADER
Authorized Official - Last Name:PREWETT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:805-489-2020
Mailing Address - Street 1:943 W GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:GROVER BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93433-2135
Mailing Address - Country:US
Mailing Address - Phone:805-489-2020
Mailing Address - Fax:
Practice Address - Street 1:943 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:GROVER BEACH
Practice Address - State:CA
Practice Address - Zip Code:93433-2135
Practice Address - Country:US
Practice Address - Phone:805-489-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VISION CENTER OF SANTA MARIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-11
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 7312 TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0073120Medicaid
CASD0073120Medicaid
CAWY192Medicare PIN