Provider Demographics
NPI:1477966026
Name:WILSON, ANDREW (OD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
Last Name:WILSON
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 1:4000 CALLE TECATE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-5282
Mailing Address - Country:US
Mailing Address - Phone:805-482-1136
Mailing Address - Fax:805-388-8499
Practice Address - Street 1:4000 CALLE TECATE
Practice Address - Street 2:#100
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-5282
Practice Address - Country:US
Practice Address - Phone:805-482-1136
Practice Address - Fax:805-388-8499
Is Sole Proprietor?:No
Enumeration Date:2014-06-10
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14926152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist