Provider Demographics
NPI:1548232945
Name:NEELY, JACK LYNN (OD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:LYNN
Last Name:NEELY
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 1:1010 N 21ST ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-2922
Mailing Address - Country:US
Mailing Address - Phone:740-366-5050
Mailing Address - Fax:740-366-4149
Practice Address - Street 1:1010 N 21ST ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-2922
Practice Address - Country:US
Practice Address - Phone:740-366-5050
Practice Address - Fax:740-366-4149
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3191T955152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0275287Medicaid
T46846Medicare UPIN
OH0426040001Medicare NSC
NE0431981Medicare PIN