MEDICARE: JEFFREY T MANTERNACH O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist		IL

General Provider Information

NPI Number	:	1093900037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY T MANTERNACH O.D.

Provider Business Mailing Address
First Line	:	1000 W LELAND AVE
Second Line	:	APT 11D
City	:	CHICAGO
State	:	IL
Zip	:	60640-3064
Country	:	US
Telephone Number	:	563-543-7174
Fax Number	:

Provider Business Practice Location Address
First Line	:	3333 W TOUHY AVE
Second Line	:	LINCOLNWOOD TOWN CENTER
City	:	LINCOLNWOOD
State	:	IL
Zip	:	60712-2721
Country	:	US
Telephone Number	:	847-675-8637
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2007
Last Update Date	:	09/12/2007

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