Individual
DR. ANTHONY JOHN VANDE WYDEVEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
OD
Contact information
Practice address
10522 VENICE BLVD, CULVER CITY, CA 90232-3308
(310) 838-0521
(310) 839-6201
Mailing address
10522 VENICE BLVD, CULVER CITY, CA 90232-3308
(310) 838-0521
(310) 839-6201
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
8132T
CA
152WC0802X
Corneal and Contact Management Optometrist
8132T
CA
152WP0200X
Pediatric Optometrist
8132T
CA
152WS0006X
Sports Vision Optometrist
8132T
CA
152WX0102X
Occupational Vision Optometrist
8132T
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
SD0081320
—
CA
Enumeration date
07/21/2006
Last updated
10/15/2009
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