Provider Demographics
NPI:1144463761
Name:WU, JENNIFER LEE (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LEE
Last Name:WU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:C
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3033 BRISTOL ST UNIT 123
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-3091
Mailing Address - Country:US
Mailing Address - Phone:949-208-9090
Mailing Address - Fax:949-546-1141
Practice Address - Street 1:3033 BRISTOL ST UNIT 123
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-3091
Practice Address - Country:US
Practice Address - Phone:949-208-9090
Practice Address - Fax:949-546-1141
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK30583207W00000X
CAA117309207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200548070AMedicaid