Provider Demographics
NPI:1750361424
Name:BOOTH, LOWELL JOHN (OD)
Entity type:Individual
Prefix:DR
First Name:LOWELL
Middle Name:JOHN
Last Name:BOOTH
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 1:1102 IRVINE BLVD
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3529
Mailing Address - Country:US
Mailing Address - Phone:714-838-3210
Mailing Address - Fax:714-838-5702
Practice Address - Street 1:1102 IRVINE BLVD
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3529
Practice Address - Country:US
Practice Address - Phone:714-838-3210
Practice Address - Fax:714-838-5702
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT4984 TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4984TOtherVBA
CASD0049840Medicaid
CA3108OtherMESC
CA3108OtherMESC
T69978Medicare UPIN
CASD0049840Medicaid
OP4984Medicare ID - Type Unspecified