Provider Demographics
NPI:1114006319
Name:WOFCHUCK, JAY MITCHELL (OD)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:MITCHELL
Last Name:WOFCHUCK
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 1:3179 HAMNER AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NORCO
Mailing Address - State:CA
Mailing Address - Zip Code:92860-1983
Mailing Address - Country:US
Mailing Address - Phone:951-734-4802
Mailing Address - Fax:951-734-3035
Practice Address - Street 1:3179 HAMNER AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:NORCO
Practice Address - State:CA
Practice Address - Zip Code:92860-1983
Practice Address - Country:US
Practice Address - Phone:951-734-4802
Practice Address - Fax:951-734-3035
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT6838T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0068380Medicaid
T10423Medicare UPIN
CASD0068380Medicaid
CASD0068380Medicare PIN