Provider Demographics
NPI:1407842529
Name:LANTZ, JERRY ALLAN (OD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:ALLAN
Last Name:LANTZ
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 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2014 DUDLEY AVE
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-3405
Practice Address - Country:US
Practice Address - Phone:304-422-1841
Practice Address - Fax:304-865-0592
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-23
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV779-D152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0150852000Medicaid
WV0478700001Medicare NSC
WV0150852000Medicaid
LA0574731Medicare ID - Type Unspecified