Provider Demographics
NPI:1881633501
Name:WADA, JON GORDON (OD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:GORDON
Last Name:WADA
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 1:2405 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-1500
Mailing Address - Country:US
Mailing Address - Phone:408-243-7916
Mailing Address - Fax:408-243-3525
Practice Address - Street 1:2405 FOREST AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1500
Practice Address - Country:US
Practice Address - Phone:408-243-7916
Practice Address - Fax:408-243-3525
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9115T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0091150Medicaid
CACA148928Medicare PIN
CASD0091150Medicaid