Provider Demographics
NPI:1417118183
Name:IRWIN, SALLY GRACE (OD)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:GRACE
Last Name:IRWIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 SW WANAMAKER RD
Mailing Address - Street 2:SUITE 192
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66614-4293
Mailing Address - Country:US
Mailing Address - Phone:785-272-0707
Mailing Address - Fax:785-272-0575
Practice Address - Street 1:3012 ANDERSON AVE
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66503-2809
Practice Address - Country:US
Practice Address - Phone:785-537-1118
Practice Address - Fax:785-537-8005
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1809152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200576690AMedicaid
KS065160001Medicare PIN
KS1417906074Medicare PIN
KS4008180003Medicare NSC
KS1417118183Medicare PIN