Healthcare Provider Details

I. General information

NPI: 1194760942
Provider Name (Legal Business Name): ALAN J MCCORMICK OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 01/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5231 E CENTRAL AVE SUITE D
WICHITA KS
67208-4195
US

IV. Provider business mailing address

1851 N WEBB RD
WICHITA KS
67206-3413
US

V. Phone/Fax

Practice location:
  • Phone: 316-683-6870
  • Fax: 316-683-6873
Mailing address:
  • Phone: 316-858-3831
  • Fax: 316-858-3830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1574
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: