Provider Demographics
NPI:1659424877
Name:SHOWALTER, JILL KRISTINE (OD)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:KRISTINE
Last Name:SHOWALTER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:KRISTINE
Other - Last Name:RITCHIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1500 GRAND CENTRAL AVE
Mailing Address - Street 2:SUITE 112
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-1079
Mailing Address - Country:US
Mailing Address - Phone:304-295-5025
Mailing Address - Fax:304-295-7178
Practice Address - Street 1:1500 GRAND CENTRAL AVE
Practice Address - Street 2:SUITE 112
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-1079
Practice Address - Country:US
Practice Address - Phone:304-295-5025
Practice Address - Fax:304-295-7178
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4683 T1458152W00000X
WV939-OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810006845Medicaid
WVU57945Medicare UPIN