=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275789000
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILBUR WU O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2008
-----------------------------------------------------
Last Update Date | 12/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 350 S LAKE AVE SUITE 111
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91101-3530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-683-6868
-----------------------------------------------------
Fax | 626-782-6162
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 350 S LAKE AVE SUITE 111
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91101-3530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-683-6868
-----------------------------------------------------
Fax | 626-782-6162
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 13593
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------