Provider Demographics
NPI:1467456194
Name:GILMORE, WAYNE R (OD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:R
Last Name:GILMORE
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 1:501 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PARSONS
Mailing Address - State:KS
Mailing Address - Zip Code:67357-3442
Mailing Address - Country:US
Mailing Address - Phone:620-421-5270
Mailing Address - Fax:620-421-8450
Practice Address - Street 1:501 MAIN ST
Practice Address - Street 2:
Practice Address - City:PARSONS
Practice Address - State:KS
Practice Address - Zip Code:67357-3442
Practice Address - Country:US
Practice Address - Phone:620-421-5270
Practice Address - Fax:620-421-8450
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1527-3152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS059865Medicare ID - Type Unspecified
KSU74713Medicare UPIN
1263070002Medicare NSC