Healthcare Provider Details

I. General information

NPI: 1326722174
Provider Name (Legal Business Name): CHARLES WU OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 04/05/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 E NIZHONI BLVD
GALLUP NM
87301-5748
US

IV. Provider business mailing address

1832 MONTAGE CT
SAN JOSE CA
95131-3421
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1326
  • Fax:
Mailing address:
  • Phone: 408-628-8147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberS-F24-TA-C96
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: