Healthcare Provider Details

I. General information

NPI: 1831603307
Provider Name (Legal Business Name): FAIRWAY EYE CENTER IN LEAWOOD INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2017
Last Update Date: 08/04/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11707 ROE AVE STE A
LEAWOOD KS
66211-2601
US

IV. Provider business mailing address

11707 ROE AVE STE A
LEAWOOD KS
66211-2601
US

V. Phone/Fax

Practice location:
  • Phone: 913-491-9123
  • Fax: 913-491-6608
Mailing address:
  • Phone: 913-491-9123
  • Fax: 913-491-6608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code156FC0800X
TaxonomyContact Lens Technician/Technologist
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code156FX1202X
TaxonomyOptometric Technician
License Number
License Number State

VIII. Authorized Official

Name: DR. MARK BUNDE
Title or Position: OPTOMETRIST
Credential: OD
Phone: 913-491-9123