MEDICARE: DR. ANTHONY JOHN VANDE WYDEVEN OD

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	8132T	CA
2	152WC0802X	Corneal and Contact Management Optometrist	8132T	CA
3	152WP0200X	Pediatric Optometrist	8132T	CA
4	152WS0006X	Sports Vision Optometrist	8132T	CA
5	152WX0102X	Occupational Vision Optometrist	8132T	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1861413304
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANTHONY JOHN VANDE WYDEVEN OD

Provider Business Mailing Address
First Line	:	10522 VENICE BLVD
Second Line	:
City	:	CULVER CITY
State	:	CA
Zip	:	90232-3308
Country	:	US
Telephone Number	:	310-838-0521
Fax Number	:	310-839-6201

Provider Business Practice Location Address
First Line	:	10522 VENICE BLVD
Second Line	:
City	:	CULVER CITY
State	:	CA
Zip	:	90232-3308
Country	:	US
Telephone Number	:	310-838-0521
Fax Number	:	310-839-6201

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

Provider Enumeration Date	:	07/21/2006
Last Update Date	:	10/15/2009

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Directions to “ DR. ANTHONY JOHN VANDE WYDEVEN OD” Practice Location

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