Provider Demographics
NPI:1144495490
Name:G DERRIL GWINNER OD LLC
Entity type:Organization
Organization Name:G DERRIL GWINNER OD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:MR
Authorized Official - First Name:G
Authorized Official - Middle Name:DERRIL
Authorized Official - Last Name:GWINNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:785-472-3272
Mailing Address - Street 1:PO BOX 339
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:67439-0339
Mailing Address - Country:US
Mailing Address - Phone:785-472-3272
Mailing Address - Fax:785-472-3360
Practice Address - Street 1:801 E 3RD ST
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:KS
Practice Address - Zip Code:67439-4224
Practice Address - Country:US
Practice Address - Phone:785-472-3272
Practice Address - Fax:785-472-3360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS9613152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100090550AMedicaid
KS0300960001Medicare NSC
KST77474Medicare UPIN
KS005239Medicare PIN