Provider Demographics
NPI:1073677613
Name:WILMER, CHRISTINA SUSANNE (OD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINA
Middle Name:SUSANNE
Last Name:WILMER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 BANCROFT EXT
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94720-4303
Mailing Address - Country:US
Mailing Address - Phone:510-643-2020
Mailing Address - Fax:510-642-9422
Practice Address - Street 1:2222 BANCROFT EXT
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94720-4303
Practice Address - Country:US
Practice Address - Phone:510-643-2020
Practice Address - Fax:510-642-9422
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10667 TPG152W00000X
NM483152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM483OtherSTATE LICENSE NUMBER
CA10667 TLGOtherSTATE LICENSE
CA10667 TLGOtherSTATE LICENSE
CAU89254Medicare UPIN
CAMW0641060OtherDEA