Provider Demographics
NPI:1679989339
Name:WU, JEFFRY (OD)
Entity type:Individual
Prefix:DR
First Name:JEFFRY
Middle Name:
Last Name:WU
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 1:112 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4756
Mailing Address - Country:US
Mailing Address - Phone:909-792-2280
Mailing Address - Fax:909-792-4872
Practice Address - Street 1:112 E STATE ST
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4756
Practice Address - Country:US
Practice Address - Phone:909-792-2280
Practice Address - Fax:909-792-4872
Is Sole Proprietor?:No
Enumeration Date:2014-07-02
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15020152WC0802X, 152WP0200X, 152WX0102X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision