Healthcare Provider Details

I. General information

NPI: 1275789000
Provider Name (Legal Business Name): WILBUR WU O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2008
Last Update Date: 12/02/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 S LAKE AVE SUITE 111
PASADENA CA
91101-3530
US

IV. Provider business mailing address

350 S LAKE AVE SUITE 111
PASADENA CA
91101-3530
US

V. Phone/Fax

Practice location:
  • Phone: 626-683-6868
  • Fax: 626-782-6162
Mailing address:
  • Phone: 626-683-6868
  • Fax: 626-782-6162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number13593
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: