Provider Demographics
NPI:1710022686
Name:LIN, JERRY T (OD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:T
Last Name:LIN
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 1:630 N ROSE DR
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-7513
Mailing Address - Country:US
Mailing Address - Phone:714-524-6688
Mailing Address - Fax:714-524-7678
Practice Address - Street 1:630 N ROSE DR
Practice Address - Street 2:
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-7513
Practice Address - Country:US
Practice Address - Phone:714-524-6688
Practice Address - Fax:714-524-7678
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11077T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0110770Medicaid
CAOP11077Medicare ID - Type Unspecified
CAU78869Medicare UPIN