Healthcare Provider Details

I. General information

NPI: 1578584769
Provider Name (Legal Business Name): JEROME WH NISWONGER MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6283 CLARK RD #10
PARADISE CA
95969-4100
US

IV. Provider business mailing address

6283 CLARK RD #10
PARADISE CA
95969-4100
US

V. Phone/Fax

Practice location:
  • Phone: 530-877-2020
  • Fax: 530-877-4641
Mailing address:
  • Phone: 530-877-2020
  • Fax: 530-877-4641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JEROME WH NISWONGER
Title or Position: OWNER/PRESIDENT
Credential: MD
Phone: 530-877-2020