Jack B Vontillius, O.D.

Primary specialty

OptometristTaxonomy code 152W00000X

License

OD0000002781 Issued in TN

Practice address

9453 Dayton Pike
Soddy Daisy, TN 37379-4751

Phone

(423) 332-8222

Fax

(423) 332-8278

NPI assigned

Nov 21, 2007

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in TN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Pearle Vision Inc

  • Eyewear Supplier
  • Fairview Heights, IL
  • NPI 1982744033
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1195603200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1372291200000",
    "number": "1194906883",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "9453 DAYTON PIKE",
            "city": "SODDY DAISY",
            "state": "TN",
            "postal_code": "373794751",
            "telephone_number": "423-332-8222",
            "fax_number": "423-332-8278"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9453 DAYTON PIKE",
            "city": "SODDY DAISY",
            "state": "TN",
            "postal_code": "373794751",
            "telephone_number": "423-332-8222",
            "fax_number": "423-332-8278"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "VONTILLIUS",
        "first_name": "JACK",
        "middle_name": "B",
        "credential": "O.D.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2007-11-21",
        "last_updated": "2013-06-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": "NY",
            "license": "TUV007223",
            "primary": false
        },
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": "TN",
            "license": "OD0000002781",
            "primary": true
        },
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": "GA",
            "license": "OP002631",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1515043",
            "state": "TN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS OF TN",
            "identifier": "4230667",
            "state": "TN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Laura T Truelove, MD
• William David Van Eaton, PT
• Danielle A Vandergriff, NP
• Vision Plus Optical
• Vital Medical Transport
• Danielle Sarah Voss, APRN
• VPT Performance
• VPT Performance LLC
• Wal-Mart Stores East LP
• Wal-Mart Stores East, LP

• All providers in Soddy Daisy, TN
• Optometrist in Tennessee

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 27, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.