Provider Demographics
NPI:1902987001
Name:PREWETT, JOHN RADER (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RADER
Last Name:PREWETT
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 1:1429 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-6913
Mailing Address - Country:US
Mailing Address - Phone:805-925-9575
Mailing Address - Fax:805-739-8886
Practice Address - Street 1:1429 S BROADWAY
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-6913
Practice Address - Country:US
Practice Address - Phone:805-925-9575
Practice Address - Fax:805-739-8886
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA7312152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0073121Medicaid
CAT70187Medicare UPIN
CAWOP7312BMedicare ID - Type Unspecified