Provider Demographics
NPI:1194027748
Name:DIAMOND VISION OPTOMETRY INC
Entity Type:Organization
Organization Name:DIAMOND VISION OPTOMETRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILBUR
Authorized Official - Middle Name:
Authorized Official - Last Name:WU
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:626-683-6868
Mailing Address - Street 1:350 S LAKE AVE
Mailing Address - Street 2:#111
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-3530
Mailing Address - Country:US
Mailing Address - Phone:626-683-6868
Mailing Address - Fax:
Practice Address - Street 1:350 S LAKE AVE
Practice Address - Street 2:#111
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-3530
Practice Address - Country:US
Practice Address - Phone:626-683-6868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-01
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13593152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAENO25AMedicare PIN