Provider Demographics
NPI:1831251552
Name:MIETUS, LAWRENCE (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:
Last Name:MIETUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5662 CALLE REAL
Mailing Address - Street 2:SUITE 341
Mailing Address - City:GOLETA
Mailing Address - State:CA
Mailing Address - Zip Code:93117-2317
Mailing Address - Country:US
Mailing Address - Phone:805-886-7914
Mailing Address - Fax:
Practice Address - Street 1:5662 CALLE REAL
Practice Address - Street 2:SUITE 341
Practice Address - City:GOLETA
Practice Address - State:CA
Practice Address - Zip Code:93117-2317
Practice Address - Country:US
Practice Address - Phone:805-886-7914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG60991174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA90031Medicare UPIN
CAG60991Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER