Provider Demographics
NPI:1154517761
Name:ROUNTREE, JACK WAYNE JR (OD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:WAYNE
Last Name:ROUNTREE
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10792 OAKLAND RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-2025
Mailing Address - Country:US
Mailing Address - Phone:210-520-0051
Mailing Address - Fax:
Practice Address - Street 1:5025 NW LOOP 410
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-5313
Practice Address - Country:US
Practice Address - Phone:210-520-0051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-18
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7076TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist