Provider Demographics
NPI:1033172903
Name:WADA, GARRETT SCOTT (OD)
Entity Type:Individual
Prefix:DR
First Name:GARRETT
Middle Name:SCOTT
Last Name:WADA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:936 S BROOKHURST ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-4305
Mailing Address - Country:US
Mailing Address - Phone:714-533-2525
Mailing Address - Fax:714-242-9564
Practice Address - Street 1:936 S BROOKHURST ST
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-4305
Practice Address - Country:US
Practice Address - Phone:714-533-2525
Practice Address - Fax:714-242-9564
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10097T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD010097Medicaid
CAOP10097Medicare ID - Type UnspecifiedMEDICARE
CASD010097Medicaid