Provider Demographics
NPI:1861413304
Name:VANDE WYDEVEN, ANTHONY JOHN (OD)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:JOHN
Last Name:VANDE WYDEVEN
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 1:10522 VENICE BLVD
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-3308
Mailing Address - Country:US
Mailing Address - Phone:310-838-0521
Mailing Address - Fax:310-839-6201
Practice Address - Street 1:10522 VENICE BLVD
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-3308
Practice Address - Country:US
Practice Address - Phone:310-838-0521
Practice Address - Fax:310-839-6201
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8132T152W00000X, 152WC0802X, 152WP0200X, 152WS0006X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0081320Medicaid
CACG950AMedicare PIN
CASD0081320Medicaid
CA5160170001Medicare NSC