Provider Demographics
NPI:1497840565
Name:MICHAEL D GORDON OD PA
Entity Type:Organization
Organization Name:MICHAEL D GORDON OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:316-684-2020
Mailing Address - Street 1:110 N WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:KS
Mailing Address - Zip Code:67152-3949
Mailing Address - Country:US
Mailing Address - Phone:620-326-2020
Mailing Address - Fax:620-326-6350
Practice Address - Street 1:110 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:KS
Practice Address - Zip Code:67152-3949
Practice Address - Country:US
Practice Address - Phone:620-326-2020
Practice Address - Fax:620-326-6350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS10462 MICHAEL D GORD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DD8359OtherRAILROAD MEDICARE
017085Medicare ID - Type UnspecifiedBCBS