Unknown Individual – Optometrist, NPI 1114021474

Optometrist

Unknown Individual is a healthcare provider. based in Crossville, Tennessee. specializing in Optometrist. They hold a License No. ODT0000000393 (TN). The NPI Number for Unknown Individual is 1114021474

Main info

Organization

Inactive

62 Years Of Experience

Accepts Medicare Assignment

Name

Unknown Individual

NPI

1114021474

Phone

(931) 456-2728

Address

15 IRIS LN

Deactivation Date

10 July 2025

Doctor Profile

Medical School Name

SOUTHERN COLLEGE OF OPTOMETRY

Secondary Phone

9314732487

Graduation Year

1964 (62 years ago)

PAC ID

3274677745

Group Practice PAC ID

1355379256

Professional Enrollment ID

I20100222000476

Data current as of

19 May 2026

Profile Insights

NPPES metrics only — not quality of care.

Methodology

Experience14

Completeness75

Years active:0State licenses:1Digital endpointsOther names

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Provider Addresses for Unknown Individual

15, Iris Lane, Lynwood Acres, Crossville, Cumberland County, Tennessee, 38555, United States
CROSSVILLE, TN 385557528
Phone: (931) 456-2728
Fax: (931) 456-5446
Type: Mailing
220, North Chancery Street, McMinnville, Warren County, Tennessee, 37110, United States
MCMINNVILLE, TN 371102551
Phone: (931) 473-2487
Type: Location

NPPES updates history

No NPPES updates recorded for this provider.

Prescription Activity

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Open Payments (CMS)

No Open Payments data available for this provider.

This can happen when there are no reportable CMS Open Payments records.

Medicare Enrollment & Revalidation

Source: CMS public data · Not endorsed by CMS ·

Educational use only—not medical, billing, or legal advice.

No Medicare enrollment or revalidation data available for this provider in our database.

Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS

Medicare Utilization (FFS)

Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·

Educational use only—not medical, billing, or legal advice.

Top Medicare procedures (2023) · refreshed 2026-05-27

HCPCS	Description	Services	Beneficiaries	Medicare allowed
92014	Established patient complete exam of visual system	13	13	$0

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Insurance plans in this area (ZIP 38555)

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Group practice members

Group practice members are other physicians who share the same Group Practice PAC ID with this doctor. When doctors form a group practice and register in PECOS as a single entity, they receive a shared identification number. This table lists all providers in the same group practice.

PAC ID: 1355379256View full group profile

Name	Specialty	State
DR. PHILIP M BROCK (OD)	O P T O M E T R Y	TN
DR. KATIE GRACE SMITH (OD)	O P T O M E T R Y	TN
DR. HOLLY N PENDEL (OD)	O P T O M E T R Y	TN
ANDREW DAVID JOHNSON (M.D.)	O P H T H A L M O L O G Y	TN
DR. JORDAN D SMITH (O.D.)	O P T O M E T R Y	TN
KAILEY THOMAS BOYNTON (OD)	O P T O M E T R Y	TN
BROOKE MILLISON LANE DAVID (OD)	O P T O M E T R Y	TN
DR. JAMES M JR. GRISOLANO (M.D.)	O P H T H A L M O L O G Y	TN
Unknown Individual	-	TN
MS. AMANDA J KIRK (O.D.)	O P T O M E T R Y	TN