Provider Demographics
NPI:1104800697
Name:LENNON, JOHN M JR (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:LENNON
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:M
Other - Last Name:LENNON
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:2504 CRILL AVE
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-4264
Mailing Address - Country:US
Mailing Address - Phone:386-328-5141
Mailing Address - Fax:386-328-3972
Practice Address - Street 1:2504 CRILL AVE
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-4264
Practice Address - Country:US
Practice Address - Phone:386-328-5141
Practice Address - Fax:386-328-5141
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2448152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078883000Medicaid
FL20313OtherBCBS
U26116Medicare UPIN
FL0936440001Medicare NSC