MEDICARE: JACK WAYNE ROUNTREE JR. OD

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	7076TG	TX

General Provider Information

NPI Number	:	1154517761
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK WAYNE ROUNTREE JR. OD

Provider Business Mailing Address
First Line	:	10792 OAKLAND RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78240-2025
Country	:	US
Telephone Number	:	210-520-0051
Fax Number	:

Provider Business Practice Location Address
First Line	:	5025 NW LOOP 410
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-5313
Country	:	US
Telephone Number	:	210-520-0051
Fax Number	:

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

Provider Enumeration Date	:	09/18/2007
Last Update Date	:	04/30/2021

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