Provider Demographics
NPI:1679645394
Name:JON A. SKILLMAN
Entity Type:Organization
Organization Name:JON A. SKILLMAN
Other - Org Name:DR JON A. SKILLMAN & ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRISTS
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:A
Authorized Official - Last Name:SKILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:270-684-3234
Mailing Address - Street 1:3625 TREEHAVEN BND
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-1785
Mailing Address - Country:US
Mailing Address - Phone:270-684-3234
Mailing Address - Fax:270-684-3151
Practice Address - Street 1:233 WILLIAMSBURG SQ
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-6473
Practice Address - Country:US
Practice Address - Phone:270-684-3234
Practice Address - Fax:270-684-3151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0773DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77007730Medicaid
KYT54642Medicare UPIN
KY77007730Medicaid
KY0694820001Medicare NSC