Healthcare Provider Details

I. General information

NPI: 1396716700
Provider Name (Legal Business Name): JOHN B GELVIN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 11/08/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 NE MULBERRY STREET SUITE 101
LEE'S SUMMIT MO
64086-4533
US

IV. Provider business mailing address

715 SW DERBY DR
LEES SUMMIT MO
64081-3277
US

V. Phone/Fax

Practice location:
  • Phone: 816-525-3937
  • Fax:
Mailing address:
  • Phone: 816-525-3937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT03486
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number14783
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: