Provider Demographics
NPI:1164413415
Name:DELANCEY, GARY WAYNE (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:WAYNE
Last Name:DELANCEY
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 1:113 OLD STATE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ELLISVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63021-2042
Mailing Address - Country:US
Mailing Address - Phone:636-256-7800
Mailing Address - Fax:636-394-1011
Practice Address - Street 1:113 OLD STATE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63021-2042
Practice Address - Country:US
Practice Address - Phone:636-256-7800
Practice Address - Fax:636-394-1011
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02255152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
100813OtherBLUE CROSS
5615221OtherAETNA
114194OtherCOLE
26258OtherAVESIS
262074OtherNVA
T02255OtherVBA
114194OtherEYEMED
12922OtherSPECTERA
26258OtherBLUE CHOICE
VP13561OtherVCA
262074OtherNVA