MEDICARE: DR. MAX STEVEN MANCILLAS O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1225-3	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1225-3	OTHER	KS	STATE LICENSE NUMBER
2	T2655	OTHER	MO	STATE LICENSE

General Provider Information

NPI Number	:	1609827971
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MAX STEVEN MANCILLAS O.D.

Provider Business Mailing Address
First Line	:	10556 BLUEJACKET ST
Second Line	:
City	:	OVERLAND PARK
State	:	KS
Zip	:	66214-3029
Country	:	US
Telephone Number	:	913-492-5417
Fax Number	:

Provider Business Practice Location Address
First Line	:	11548 W 135TH ST
Second Line	:
City	:	OVERLAND PARK
State	:	KS
Zip	:	66221-2892
Country	:	US
Telephone Number	:	913-814-7600
Fax Number	:	913-814-3906

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/12/2006
Last Update Date	:	03/07/2023

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