Healthcare Provider Details

I. General information

NPI: 1811993629
Provider Name (Legal Business Name): G. BARNARD WILSON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 02/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1317 OAKDALE RD STE 620
MODESTO CA
95355-3365
US

IV. Provider business mailing address

1317 OAKDALE RD STE 620
MODESTO CA
95355-3365
US

V. Phone/Fax

Practice location:
  • Phone: 209-524-7870
  • Fax: 209-524-7985
Mailing address:
  • Phone: 209-524-7870
  • Fax: 209-524-7985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5347T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: