Provider Demographics
NPI:1629116827
Name:MENGOLI, JEAN MARIE WANG (OD)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:MARIE WANG
Last Name:MENGOLI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JEAN
Other - Middle Name:MARIE
Other - Last Name:WANG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:4405 VANDEVER AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-3315
Mailing Address - Country:US
Mailing Address - Phone:503-936-4136
Mailing Address - Fax:
Practice Address - Street 1:4405 VANDEVER AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-3315
Practice Address - Country:US
Practice Address - Phone:503-936-4136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11975T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist