Provider Demographics
NPI:1467435164
Name:OTA, WESLEY TAKASHI (OD)
Entity Type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:TAKASHI
Last Name:OTA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:10535 HOSPITAL WAY
Mailing Address - Street 2:
Mailing Address - City:MATHER
Mailing Address - State:CA
Mailing Address - Zip Code:95655-4200
Mailing Address - Country:US
Mailing Address - Phone:916-366-5466
Mailing Address - Fax:
Practice Address - Street 1:10535 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:MATHER
Practice Address - State:CA
Practice Address - Zip Code:95655-4200
Practice Address - Country:US
Practice Address - Phone:916-366-5466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA9590T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist