Provider Demographics
NPI:1043624836
Name:WELLS, BRENT RYAN (OD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:RYAN
Last Name:WELLS
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 1:2231 BAYVIEW HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:LOS OSOS
Mailing Address - State:CA
Mailing Address - Zip Code:93402-3900
Mailing Address - Country:US
Mailing Address - Phone:805-528-5333
Mailing Address - Fax:
Practice Address - Street 1:2231 BAYVIEW HEIGHTS DR
Practice Address - Street 2:
Practice Address - City:LOS OSOS
Practice Address - State:CA
Practice Address - Zip Code:93402-3900
Practice Address - Country:US
Practice Address - Phone:805-528-5333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-19
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14982152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist