Healthcare Provider Details

I. General information

NPI: 1164413415
Provider Name (Legal Business Name): GARY WAYNE DELANCEY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 OLD STATE RD SUITE 101
ELLISVILLE MO
63021-2042
US

IV. Provider business mailing address

113 OLD STATE RD SUITE 101
ELLISVILLE MO
63021-2042
US

V. Phone/Fax

Practice location:
  • Phone: 636-256-7800
  • Fax: 636-394-1011
Mailing address:
  • Phone: 636-256-7800
  • Fax: 636-394-1011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT02255
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberT02255
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: