Provider Demographics
NPI:1720591480
Name:JEFFRY WU O.D. PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:JEFFRY WU O.D. PROFESSIONAL CORPORATION
Other - Org Name:STATE STREET OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFRY
Authorized Official - Middle Name:
Authorized Official - Last Name:WU
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:909-792-2280
Mailing Address - Street 1:112 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4756
Mailing Address - Country:US
Mailing Address - Phone:909-792-2280
Mailing Address - Fax:909-792-4872
Practice Address - Street 1:112 E STATE ST
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4756
Practice Address - Country:US
Practice Address - Phone:909-792-2280
Practice Address - Fax:909-792-4872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-15
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15020152W00000X, 152WC0802X, 152WP0200X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty
No152WX0102XEye and Vision Services ProvidersOptometristOccupational VisionGroup - Single Specialty