Provider Demographics
NPI:1215047063
Name:GUENTHER, JACK G (OD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:G
Last Name:GUENTHER
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 1:19607 S LAGRANGE ROAD
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448
Mailing Address - Country:US
Mailing Address - Phone:708-479-1616
Mailing Address - Fax:708-479-6699
Practice Address - Street 1:19607 S LAGRANGE ROAD
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448
Practice Address - Country:US
Practice Address - Phone:708-479-1616
Practice Address - Fax:708-479-6699
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008314152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U78463Medicare UPIN
IL564560Medicare PIN