Provider Demographics
NPI:1972636447
Name:ATHEY, WESLEY GORDON CHARLES (OD)
Entity Type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:GORDON CHARLES
Last Name:ATHEY
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 1:4619 LA LOMA ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78233-6729
Mailing Address - Country:US
Mailing Address - Phone:210-410-6601
Mailing Address - Fax:
Practice Address - Street 1:4619 LA LOMA ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78233-6729
Practice Address - Country:US
Practice Address - Phone:210-410-6601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7035T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX210669201Medicaid
11763257OtherCAQH
TX210669201Medicaid
11763257OtherCAQH
U81368Medicare UPIN