Provider Demographics
NPI:1588785786
Name:IDOCS OF DODGE CITY, PA
Entity type:Organization
Organization Name:IDOCS OF DODGE CITY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:GWALTNEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:620-227-3071
Mailing Address - Street 1:2520 N 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:DODGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67801-2315
Mailing Address - Country:US
Mailing Address - Phone:620-227-3071
Mailing Address - Fax:620-227-6911
Practice Address - Street 1:2520 N 14TH AVE
Practice Address - Street 2:
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801-2315
Practice Address - Country:US
Practice Address - Phone:620-227-3071
Practice Address - Fax:620-227-6911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1744152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100090850AMedicaid
KS043311OtherBCBS GROUP #
KS200399790AMedicaid
KS100219900AMedicaid
KSC57955OtherRR MEDICARE
KS200399790AMedicaid
KS043311OtherBCBS GROUP #