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General NPI Number Information
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NPI Number | 1124179908
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Entity Type | Individual
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Provider Name | JULIE ANN WAGSTAFF O.D.
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Gender | Female
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Dates
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Enumeration Date | 01/16/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2200 EASTRIDGE LOOP EASTRIDGE MALL STE 1078
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City | SAN JOSE
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State | CA
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Zip | 95122-1410
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Country | US
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Telephone | 408-270-6161
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Fax | 408-270-6176
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Provider Business Mailing Address
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Address Line | 961 SPENCER AVE
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City | SAN JOSE
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State | CA
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Zip | 95125-1672
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Country | US
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Telephone | 408-947-1193
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 11444
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License Number State | CA
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