Provider Demographics
NPI:1356366546
Name:WILSON, LANI KIKU HIROTA (OD)
Entity type:Individual
Prefix:DR
First Name:LANI
Middle Name:KIKU HIROTA
Last Name:WILSON
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 1:5789 MISSION CENTER RD
Mailing Address - Street 2:APT. 315
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4316
Mailing Address - Country:US
Mailing Address - Phone:916-521-3269
Mailing Address - Fax:
Practice Address - Street 1:5789 MISSION CENTER RD APT 315
Practice Address - Street 2:(NOTE: RESIDENTIAL. NO BUSINESS LOCATION YET)
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4916
Practice Address - Country:US
Practice Address - Phone:916-521-3269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001417152W00000X
CA12078T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA680437386OtherEMPLOYMENT IDENTIFICATION