Provider Demographics
NPI:1093900037
Name:MANTERNACH, JEFFREY T (OD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:T
Last Name:MANTERNACH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W LELAND AVE
Mailing Address - Street 2:APT 11D
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-3064
Mailing Address - Country:US
Mailing Address - Phone:563-543-7174
Mailing Address - Fax:
Practice Address - Street 1:3333 W TOUHY AVE
Practice Address - Street 2:LINCOLNWOOD TOWN CENTER
Practice Address - City:LINCOLNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60712-2721
Practice Address - Country:US
Practice Address - Phone:847-675-8637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist