Provider Demographics
NPI:1538901269
Name:HAUCK-WILSON, COLE RYAN (OD)
Entity type:Individual
Prefix:
First Name:COLE
Middle Name:RYAN
Last Name:HAUCK-WILSON
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 1:19389 N 59TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6500
Mailing Address - Country:US
Mailing Address - Phone:623-537-6000
Mailing Address - Fax:
Practice Address - Street 1:5865 W UTOPIA RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-5251
Practice Address - Country:US
Practice Address - Phone:623-537-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-12
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOPT-002800152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist