Provider Demographics
NPI:1710129713
Name:G DERRIL GWINNER, O.D. L.L.C.
Entity Type:Organization
Organization Name:G DERRIL GWINNER, O.D. L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:MR
Authorized Official - First Name:G.
Authorized Official - Middle Name:DERRIL
Authorized Official - Last Name:GWINNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:785-472-3272
Mailing Address - Street 1:PO BOX 268
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:KS
Mailing Address - Zip Code:67455-0268
Mailing Address - Country:US
Mailing Address - Phone:785-524-5244
Mailing Address - Fax:
Practice Address - Street 1:208 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:KS
Practice Address - Zip Code:67455-1920
Practice Address - Country:US
Practice Address - Phone:785-524-5244
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-06
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS9613152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS017277OtherMEDICARE ID - TYPE UNSPECIFIED
KS100090550BMedicaid
KS017277OtherMEDICARE ID - TYPE UNSPECIFIED
KS100090550BMedicaid