Provider Demographics
NPI:1730283904
Name:VENCILL, JOHN C (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:VENCILL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:2933 SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-6252
Mailing Address - Country:US
Mailing Address - Phone:678-485-8906
Mailing Address - Fax:770-474-0698
Practice Address - Street 1:1400 HUDSON BRIDGE RD
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-5018
Practice Address - Country:US
Practice Address - Phone:678-485-8906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT000970152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU01765Medicare UPIN
GA41ZCBLNMedicare PIN