Provider Demographics
NPI:1659378461
Name:GERSON, JEFFRY DAVID (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFRY
Middle Name:DAVID
Last Name:GERSON
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 1:21020 W 151ST ST
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66061-7200
Mailing Address - Country:US
Mailing Address - Phone:913-829-5511
Mailing Address - Fax:913-829-5571
Practice Address - Street 1:21020 W 151ST ST
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-7200
Practice Address - Country:US
Practice Address - Phone:913-829-5511
Practice Address - Fax:913-829-5571
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2017-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03413152W00000X
KS1519-3152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
25144105OtherBLUE CROSS BLUE SHIELD KC
25144105OtherBLUE CROSS BLUE SHIELD KC
KSF328457Medicare ID - Type UnspecifiedKS MEDICARE
MO1448457Medicare ID - Type UnspecifiedMISSOURI MEDICARE