Provider Demographics
NPI:1275789000
Name:WU, WILBUR (OD)
Entity Type:Individual
Prefix:DR
First Name:WILBUR
Middle Name:
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 1:350 S LAKE AVE
Mailing Address - Street 2:SUITE 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:626-782-6162
Practice Address - Street 1:350 S LAKE AVE
Practice Address - Street 2:SUITE 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:626-782-6162
Is Sole Proprietor?:No
Enumeration Date:2008-08-12
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13593152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPTAN BX120VMedicare PIN