MEDICARE: JEROME WH NISWONGER MD INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician

General Provider Information

NPI Number	:	1093979536
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JEROME WH NISWONGER MD INC

Provider Business Mailing Address
First Line	:	6283 CLARK RD
Second Line	:	STE. 10
City	:	PARADISE
State	:	CA
Zip	:	95969-4100
Country	:	US
Telephone Number	:	530-877-2020
Fax Number	:	530-877-4641

Provider Business Practice Location Address
First Line	:	245 N VILLA AVE
Second Line	:
City	:	WILLOWS
State	:	CA
Zip	:	95988-2607
Country	:	US
Telephone Number	:	530-877-2020
Fax Number	:	530-877-4641

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JEROME NISWONGER
Credential	:	M.D.
Telephone Number	:	530-877-2020

Provider Enumeration Date	:	07/14/2008
Last Update Date	:	07/14/2008

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