Provider Demographics
NPI:1114039583
Name:BUMGARDNER, HENRY LEE JR (OD)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:LEE
Last Name:BUMGARDNER
Suffix:JR
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 1:2205 S SENECA ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67213-4224
Mailing Address - Country:US
Mailing Address - Phone:316-264-9131
Mailing Address - Fax:316-264-4649
Practice Address - Street 1:2205 S SENECA ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67213-4224
Practice Address - Country:US
Practice Address - Phone:316-264-9131
Practice Address - Fax:316-264-4649
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2008-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS997-3152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS3239530OtherCIGNA
KS480801828OtherFEDERAL IDENTIFICATION #
KS130OtherPREFERRED PLUS KANSAS
KS333128OtherCOVENTRY
KS997-3OtherKANSAS OPTOMETRY LICENSE
KS005262OtherBLUE CROSS BLUE SHIELD
KSP00620211Medicare PIN
KS3239530OtherCIGNA
KS997-3OtherKANSAS OPTOMETRY LICENSE
KS130OtherPREFERRED PLUS KANSAS