Provider Demographics
NPI:1184744641
Name:WADA OPTOMETRY, INC.
Entity type:Organization
Organization Name:WADA OPTOMETRY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GARRETT
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:WADA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:714-533-2525
Mailing Address - Street 1:936 S BROOKHURST ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-4305
Mailing Address - Country:US
Mailing Address - Phone:714-533-2525
Mailing Address - Fax:714-242-9564
Practice Address - Street 1:936 S BROOKHURST ST
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-4305
Practice Address - Country:US
Practice Address - Phone:714-533-2525
Practice Address - Fax:714-242-9564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10097T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD010097Medicaid
CASD010097Medicaid
CA6050470001Medicare NSC
CAOP10097Medicare UPIN
CAU44131Medicare UPIN