Provider Demographics
NPI:1538796578
Name:PHU, WILSON (OD)
Entity type:Individual
Prefix:
First Name:WILSON
Middle Name:
Last Name:PHU
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:WILSON
Other - Middle Name:M
Other - Last Name:PHU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:4621 CONRAD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-2018
Mailing Address - Country:US
Mailing Address - Phone:858-952-2869
Mailing Address - Fax:
Practice Address - Street 1:3345 ROSECRANS ST STE B
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4225
Practice Address - Country:US
Practice Address - Phone:619-539-7279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-26
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34534152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist