Provider Demographics
NPI:1881627768
Name:WILEY, SIDNEY JOHN (OD)
Entity type:Individual
Prefix:DR
First Name:SIDNEY
Middle Name:JOHN
Last Name:WILEY
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 1:1305 N H ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-8138
Mailing Address - Country:US
Mailing Address - Phone:805-736-3488
Mailing Address - Fax:805-737-0346
Practice Address - Street 1:1305 N H ST
Practice Address - Street 2:SUITE E
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-8138
Practice Address - Country:US
Practice Address - Phone:805-736-3488
Practice Address - Fax:805-737-0346
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABOL 6387152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist