Provider Demographics
NPI:1487766069
Name:WU, JENG REN (MD)
Entity type:Individual
Prefix:
First Name:JENG
Middle Name:REN
Last Name:WU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CHRIS
Other - Middle Name:JENG-REN
Other - Last Name:WU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:355 E 21ST STREET
Mailing Address - Street 2:SUITE G
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-3808
Mailing Address - Country:US
Mailing Address - Phone:909-886-8618
Mailing Address - Fax:909-886-3935
Practice Address - Street 1:355 E 21ST ST
Practice Address - Street 2:SUITE G
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-4851
Practice Address - Country:US
Practice Address - Phone:909-886-8618
Practice Address - Fax:909-886-3935
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC39737207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C397370Medicaid
CA00C397370Medicaid
A89089Medicare UPIN