Provider Demographics
NPI:1013072396
Name:WAKABAYASHI, DAVID TADAO (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:TADAO
Last Name:WAKABAYASHI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14150 CULVER DR STE 207
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-0323
Mailing Address - Country:US
Mailing Address - Phone:949-552-2020
Mailing Address - Fax:949-552-6777
Practice Address - Street 1:14150 CULVER DR STE 207
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-0323
Practice Address - Country:US
Practice Address - Phone:949-552-2020
Practice Address - Fax:949-552-6777
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT5223TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
BY186AMedicare PIN
20949Medicare UPIN