Provider Demographics
NPI:1427026384
Name:GILLENWATER, DAVID (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:GILLENWATER
Suffix:
Gender:M
Credentials:MD
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 48037
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-8037
Mailing Address - Country:US
Mailing Address - Phone:316-685-6112
Mailing Address - Fax:316-652-0340
Practice Address - Street 1:3515 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-3633
Practice Address - Country:US
Practice Address - Phone:620-792-2511
Practice Address - Fax:316-652-0340
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0421903207L00000X, 207LA0401X, 207LC0200X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction Medicine
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS045282OtherBCBS
050022332OtherRAILROAD MEDICARE
KS100142910AMedicaid
481129529OtherTRICARE
045282Medicare ID - Type Unspecified
045282Medicare PIN
KS045282OtherBCBS
KS100142910AMedicaid