Healthcare Provider Details

I. General information

NPI: 1922401785
Provider Name (Legal Business Name): MR. JESSE C HIDALGO JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2014
Last Update Date: 06/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10318 W MAPLE ST
WICHITA KS
67209
US

IV. Provider business mailing address

200 N BALTIMORE AVE STE 200
DERBY KS
67037-1616
US

V. Phone/Fax

Practice location:
  • Phone: 316-558-2100
  • Fax: 316-558-5229
Mailing address:
  • Phone: 316-737-9344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number986
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number741
License Number StateNE
# 3
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number1117
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: