Provider Demographics
NPI:1538713672
Name:WANG, JAIME (OD)
Entity type:Individual
Prefix:
First Name:JAIME
Middle Name:
Last Name:WANG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BEND
Mailing Address - State:WA
Mailing Address - Zip Code:98045-9175
Mailing Address - Country:US
Mailing Address - Phone:985-641-2252
Mailing Address - Fax:
Practice Address - Street 1:126 E 2ND ST
Practice Address - Street 2:
Practice Address - City:NORTH BEND
Practice Address - State:WA
Practice Address - Zip Code:98045-9175
Practice Address - Country:US
Practice Address - Phone:425-831-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD61276733152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2225979Medicaid