Provider Demographics
NPI:1578584769
Name:JEROME WH NISWONGER MD INC
Entity Type:Organization
Organization Name:JEROME WH NISWONGER MD INC
Other - Org Name:EYE LIFE INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:WH
Authorized Official - Last Name:NISWONGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-877-2020
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Not Answered207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ22165ZOtherBLUE CROSS
CAZZZ22165ZOtherBLUE SHIELD
CAZZZ22165ZMedicare ID - Type Unspecified