Provider Demographics
NPI:1285656280
Name:NISWONGER, JEROME WH (MD)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:WH
Last Name:NISWONGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6283 CLARK RD
Mailing Address - Street 2:#10
Mailing Address - City:PARADISE
Mailing Address - State:CA
Mailing Address - Zip Code:95969-4100
Mailing Address - Country:US
Mailing Address - Phone:530-877-2020
Mailing Address - Fax:530-877-4641
Practice Address - Street 1:6283 CLARK RD
Practice Address - Street 2:#10
Practice Address - City:PARADISE
Practice Address - State:CA
Practice Address - Zip Code:95969-4100
Practice Address - Country:US
Practice Address - Phone:530-877-2020
Practice Address - Fax:530-877-4641
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA20695207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A206950Medicaid
CAA22279Medicare UPIN
CA00A206950Medicaid