Organization
IDOCS OF DODGE CITY, PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JORDAN E GWALTNEY O.D. (OPTOMETRIST)
(620) 227-3071
Entity
Organization
Contact information
Practice address
2520 N 14TH AVE, DODGE CITY, KS 67801-2315
(620) 227-3071
(620) 227-6911
Mailing address
2520 N 14TH AVE, DODGE CITY, KS 67801-2315
(620) 227-3071
(620) 227-6911
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
1744
KS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
043311
BCBS GROUP #
KS
05
—
100090850A
—
KS
05
—
100219900A
—
KS
05
—
200399790A
—
KS
01
—
C57955
RR MEDICARE
KS
Enumeration date
04/03/2007
Last updated
06/05/2009
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