Brady L Wilborn, O.D.
Individual provider Active NPI Optometrist · California, MO
NPI 1124025879 · NPPES record last updated Jul 19, 2007
Key facts
- NPI
- 1124025879
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Optometrist 152W00000X
- License
- 168620 (MO)
- Practice address
- 202 E North St
California, MO 65018-1583 - Phone
- (573) 796-2222
- Fax
- (573) 796-4184
- NPI assigned
- Jul 7, 2005
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 1608 | KS | MD | Clinical Social Worker |
| 168620 | MO | MD | Optometrist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Walters Optometry, LLC | Optometrist | Past |
Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist | 152W00000X | 1608 | KS | |
| Optometrist | 152W00000X | 168620 | MO | Yes |
Addresses
Primary practice location
202 E North St
California, MO 65018-1583
Mailing address
202 E North St
California, MO 65018-1583
Phone (573) 796-2222
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 100406140B | Medicaid | KS |
Other providers in California, MO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 19, 2007. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.