Provider Demographics
NPI:1013033059
Name:WAKE, JERRY STANLEY (OD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:STANLEY
Last Name:WAKE
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 1:1630 W REDONDO BEACH BLVD
Mailing Address - Street 2:SUITE #1
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-3200
Mailing Address - Country:US
Mailing Address - Phone:310-324-8205
Mailing Address - Fax:
Practice Address - Street 1:1630 W REDONDO BEACH BLVD
Practice Address - Street 2:SUITE #1
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-3200
Practice Address - Country:US
Practice Address - Phone:310-324-8205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5790T152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU61000Medicare UPIN