Provider Demographics
NPI:1154395713
Name:LIN, JEANNIE WONG (OD)
Entity type:Individual
Prefix:
First Name:JEANNIE
Middle Name:WONG
Last Name:LIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JEANNIE
Other - Middle Name:ANN
Other - Last Name:WONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:491 30 ST
Mailing Address - Street 2:STE 101
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609
Mailing Address - Country:US
Mailing Address - Phone:516-444-0603
Mailing Address - Fax:510-872-3119
Practice Address - Street 1:491 30 ST
Practice Address - Street 2:STE 101
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609
Practice Address - Country:US
Practice Address - Phone:516-444-0603
Practice Address - Fax:510-872-3119
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT11238152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS70112780Medicaid
479449Medicare UPIN
CAS70112780Medicaid