Provider Demographics
NPI:1780653394
Name:SCHLETZBAUM, JEFFERY J (OD)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:J
Last Name:SCHLETZBAUM
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 1:2311 N WALDRON ST
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:KS
Mailing Address - Zip Code:67502-1133
Mailing Address - Country:US
Mailing Address - Phone:620-663-4467
Mailing Address - Fax:620-663-5007
Practice Address - Street 1:2311 N WALDRON ST
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67502-1133
Practice Address - Country:US
Practice Address - Phone:620-663-4467
Practice Address - Fax:620-663-5007
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1663152W00000X, 152WC0802X, 152WP0200X, 152WS0006X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
464910OtherKANSAS HEALTHWAVE
4901160002OtherDMERC
P00016824OtherRAILROAD MEDICARE
KS200252620AMedicaid
650948Medicare ID - Type Unspecified
464910OtherKANSAS HEALTHWAVE
KS200252620AMedicaid