Provider Demographics
NPI:1255404802
Name:WREN, PHILIP (OD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:
Last Name:WREN
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 1:6545 GUNPARK DR
Mailing Address - Street 2:STE 250
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-3347
Mailing Address - Country:US
Mailing Address - Phone:303-530-1973
Mailing Address - Fax:720-638-1223
Practice Address - Street 1:6545 GUNPARK DR
Practice Address - Street 2:STE 250
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-3347
Practice Address - Country:US
Practice Address - Phone:303-530-1973
Practice Address - Fax:720-638-1223
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1938152W00000X
GA1652152W00000X
CA12089T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
11798239OtherCAQH
CO69172587Medicaid
11798239OtherCAQH
11798239OtherCAQH