Provider Demographics
NPI:1417986894
Name:NIERNBERGER, GERALD E (DO)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:E
Last Name:NIERNBERGER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8035
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-0035
Mailing Address - Country:US
Mailing Address - Phone:316-689-9135
Mailing Address - Fax:316-689-9102
Practice Address - Street 1:14700 W SAINT TERESA ST STE 300
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67235-9630
Practice Address - Country:US
Practice Address - Phone:316-274-0142
Practice Address - Fax:316-719-1021
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS207Q00000X207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS014394OtherBCBS
KS16858OtherCOVENTRY
KS100302OtherHPK
KS100231520AMedicaid
KS12149386OtherMULTIPLAN
KS681OtherPHS
KS014394Medicare ID - Type Unspecified
KS100231520AMedicaid