Provider Demographics
NPI:1710503412
Name:GARDNER, JEREMY RUSSELL (OD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:RUSSELL
Last Name:GARDNER
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 1:754 N TOH N HAH TRL
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-4536
Mailing Address - Country:US
Mailing Address - Phone:480-729-2150
Mailing Address - Fax:
Practice Address - Street 1:746 N MAIZE RD STE 100
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-4571
Practice Address - Country:US
Practice Address - Phone:316-665-7647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOPT-002433152W00000X
KS2117152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist