MEDICARE: DR. LANI KIKU HIROTA WILSON O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	0618001417	VA
2	152W00000X	Optometrist	12078T	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	680437386	OTHER	VA	EMPLOYMENT IDENTIFICATION

General Provider Information

NPI Number	:	1356366546
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LANI KIKU HIROTA WILSON O.D.

Provider Business Mailing Address
First Line	:	5789 MISSION CENTER RD
Second Line	:	APT. 315
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-4316
Country	:	US
Telephone Number	:	916-521-3269
Fax Number	:

Provider Business Practice Location Address
First Line	:	5789 MISSION CENTER RD APT 315
Second Line	:	(NOTE: RESIDENTIAL. NO BUSINESS LOCATION YET)
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-4916
Country	:	US
Telephone Number	:	916-521-3269
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	06/20/2013

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Directions to “ DR. LANI KIKU HIROTA WILSON O.D.” Practice Location

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