Provider Demographics
NPI:1003104365
Name:JONES, SANDRA K (OD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:K
Last Name:JONES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:K
Other - Last Name:SEAGRAVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:211 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6220
Mailing Address - Country:US
Mailing Address - Phone:618-462-9818
Mailing Address - Fax:314-741-4947
Practice Address - Street 1:7200 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-7522
Practice Address - Country:US
Practice Address - Phone:440-946-8809
Practice Address - Fax:440-269-7942
Is Sole Proprietor?:No
Enumeration Date:2011-07-20
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002911152W00000X
SC1903152W00000X
OHOPT.006551152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD19036Medicaid
SCSC6560A804Medicare PIN