Healthcare Provider Details

I. General information

NPI: 1124511399
Provider Name (Legal Business Name): ANDREW DECLERK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2018
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9350 E 35TH ST N STE 103
WICHITA KS
67226-2022
US

IV. Provider business mailing address

551 N HILLSIDE ST STE 201
WICHITA KS
67214-4925
US

V. Phone/Fax

Practice location:
  • Phone: 316-263-0296
  • Fax:
Mailing address:
  • Phone: 316-263-0296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number04-50892
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number04-50892
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: