Individual
JACK B VONTILLIUS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
O.D.
Contact information
Practice address
9453 DAYTON PIKE, SODDY DAISY, TN 37379-4751
(423) 332-8222
(423) 332-8278
Mailing address
9453 DAYTON PIKE, SODDY DAISY, TN 37379-4751
(423) 332-8222
(423) 332-8278
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
OD0000002781
TN
152W00000X
Optometrist
OP002631
GA
152W00000X
Optometrist
TUV007223
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1515043
—
TN
01
—
4230667
BCBS OF TN
TN
Enumeration date
11/21/2007
Last updated
06/27/2013
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