Provider Demographics
NPI:1245382738
Name:GONG, JENNIFER W (OD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:W
Last Name:GONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5345 SUNRISE BLVD
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-3546
Mailing Address - Country:US
Mailing Address - Phone:949-364-4010
Mailing Address - Fax:
Practice Address - Street 1:555 SHOPS AT MISSION VIEJO
Practice Address - Street 2:STE 30 SHOPS AT MISSION VIEJO
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691
Practice Address - Country:US
Practice Address - Phone:949-364-4010
Practice Address - Fax:949-364-4001
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13028152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist