Provider Demographics
NPI:1902967516
Name:JON G. WADA, O.D.
Entity Type:Organization
Organization Name:JON G. WADA, O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:WADA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:408-243-7916
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9115152W00000X, 152WC0802X, 152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0091150Medicaid
CACA148928Medicare PIN
CAU27724Medicare UPIN