Healthcare Provider Details

I. General information

NPI: 1588785786
Provider Name (Legal Business Name): IDOCS OF DODGE CITY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 06/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 N 14TH AVE
DODGE CITY KS
67801-2315
US

IV. Provider business mailing address

2520 N 14TH AVE
DODGE CITY KS
67801-2315
US

V. Phone/Fax

Practice location:
  • Phone: 620-227-3071
  • Fax: 620-227-6911
Mailing address:
  • Phone: 620-227-3071
  • Fax: 620-227-6911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1744
License Number StateKS

VIII. Authorized Official

Name: DR. JORDAN E GWALTNEY
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 620-227-3071