Provider Demographics
NPI:1174661979
Name:WU, JOHNNY T (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:T
Last Name:WU
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 1:12070 CARMEL MOUNTAIN RD STE 292
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-4651
Mailing Address - Country:US
Mailing Address - Phone:858-676-3926
Mailing Address - Fax:858-676-3927
Practice Address - Street 1:12070 CARMEL MOUNTAIN RD STE 292
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-4651
Practice Address - Country:US
Practice Address - Phone:858-676-3926
Practice Address - Fax:858-676-3927
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12469T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU99511Medicare UPIN