Healthcare Provider Details

I. General information

NPI: 1790621803
Provider Name (Legal Business Name): MR. DONNY V. WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S GREENWOOD AVE APT 4
PASADENA CA
91107-4702
US

IV. Provider business mailing address

100 S GREENWOOD AVE APT 4
PASADENA CA
91107-4702
US

V. Phone/Fax

Practice location:
  • Phone: 951-478-7087
  • Fax:
Mailing address:
  • Phone: 951-478-7087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1234
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: