Provider Demographics
NPI:1801943733
Name:RABY, JACK W (LDO)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:W
Last Name:RABY
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:343 GILL ST
Mailing Address - Street 2:
Mailing Address - City:ALCOA
Mailing Address - State:TN
Mailing Address - Zip Code:37701-2415
Mailing Address - Country:US
Mailing Address - Phone:865-982-5317
Mailing Address - Fax:865-982-5935
Practice Address - Street 1:343 GILL ST
Practice Address - Street 2:
Practice Address - City:ALCOA
Practice Address - State:TN
Practice Address - Zip Code:37701-2415
Practice Address - Country:US
Practice Address - Phone:865-982-5317
Practice Address - Fax:865-982-5935
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPO 446156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1295490001Medicare NSC