Provider Demographics
NPI:1760450845
Name:WING, JOHN GERALD (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:GERALD
Last Name:WING
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:P.O. BOX 186
Mailing Address - Street 2:
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307-2400
Mailing Address - Country:US
Mailing Address - Phone:209-537-8971
Mailing Address - Fax:209-537-8974
Practice Address - Street 1:1901 MITCHELL RD
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-2400
Practice Address - Country:US
Practice Address - Phone:209-537-8971
Practice Address - Fax:209-537-8974
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5018T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0347120001Medicare NSC
CATO9854Medicare UPIN