Healthcare Provider Details

I. General information

NPI: 1144463761
Provider Name (Legal Business Name): JENNIFER LEE WU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER C. LEE M.D.

II. Dates (important events)

Enumeration Date: 04/13/2009
Last Update Date: 03/07/2023
Certification Date: 03/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3033 BRISTOL ST UNIT 123
COSTA MESA CA
92626-3091
US

IV. Provider business mailing address

3033 BRISTOL ST UNIT 123
COSTA MESA CA
92626-3091
US

V. Phone/Fax

Practice location:
  • Phone: 949-208-9090
  • Fax: 949-546-1141
Mailing address:
  • Phone: 949-208-9090
  • Fax: 949-546-1141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number30583
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberA117309
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: