Provider Demographics
NPI:1336228667
Name:WON, JORGE (OD)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:WON
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 1:84 07 ROOSEVELT AVENUE
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372
Mailing Address - Country:US
Mailing Address - Phone:718-651-2020
Mailing Address - Fax:718-651-2034
Practice Address - Street 1:84 07 ROOSEVELT AVENUE
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372
Practice Address - Country:US
Practice Address - Phone:718-651-2020
Practice Address - Fax:718-651-2034
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV0045621152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00909999Medicaid
T49031Medicare UPIN
NY00909999Medicaid