Provider Demographics
NPI:1194906883
Name:VONTILLIUS, JACK B (OD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:B
Last Name:VONTILLIUS
Suffix:
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 1:9453 DAYTON PIKE
Mailing Address - Street 2:
Mailing Address - City:SODDY DAISY
Mailing Address - State:TN
Mailing Address - Zip Code:37379-4751
Mailing Address - Country:US
Mailing Address - Phone:423-332-8222
Mailing Address - Fax:423-332-8278
Practice Address - Street 1:9453 DAYTON PIKE
Practice Address - Street 2:
Practice Address - City:SODDY DAISY
Practice Address - State:TN
Practice Address - Zip Code:37379-4751
Practice Address - Country:US
Practice Address - Phone:423-332-8222
Practice Address - Fax:423-332-8278
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-21
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007223152W00000X
TNOD0000002781152W00000X
GAOP002631152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1515043Medicaid
TN4230667OtherBCBS OF TN
3948006Medicare UPIN