Provider Demographics
NPI:1922120781
Name:WU, USANA (OD)
Entity Type:Individual
Prefix:DR
First Name:USANA
Middle Name:
Last Name:WU
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 COVE WAY
Mailing Address - Street 2:#504
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-5882
Mailing Address - Country:US
Mailing Address - Phone:617-770-4204
Mailing Address - Fax:617-770-4204
Practice Address - Street 1:200 COVE WAY
Practice Address - Street 2:#504
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-5882
Practice Address - Country:US
Practice Address - Phone:617-770-4204
Practice Address - Fax:617-770-4204
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3672152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0391794Medicaid
MAWU464158Medicare ID - Type Unspecified