Provider Demographics
NPI:1124179908
Name:WAGSTAFF, JULIE ANN (OD)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:ANN
Last Name:WAGSTAFF
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 1:961 SPENCER AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-1672
Mailing Address - Country:US
Mailing Address - Phone:408-947-1193
Mailing Address - Fax:
Practice Address - Street 1:2200 EASTRIDGE LOOP
Practice Address - Street 2:EASTRIDGE MALL STE 1078
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95122-1410
Practice Address - Country:US
Practice Address - Phone:408-270-6161
Practice Address - Fax:408-270-6176
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11444152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU91691Medicare UPIN
CASDO114441Medicare ID - Type Unspecified