Provider Demographics
NPI:1083689459
Name:OLLENBURGER, JARYL (OD)
Entity Type:Individual
Prefix:
First Name:JARYL
Middle Name:
Last Name:OLLENBURGER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1851 N WEBB RD
Mailing Address - Street 2:ATTN FLR2
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-3413
Mailing Address - Country:US
Mailing Address - Phone:316-636-2010
Mailing Address - Fax:316-858-3830
Practice Address - Street 1:3607 N RIDGE RD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205
Practice Address - Country:US
Practice Address - Phone:316-721-2701
Practice Address - Fax:316-721-8612
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS10202152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KST43759Medicare UPIN
KS650728Medicare PIN