Provider Demographics
NPI:1851350706
Name:ERNZEN, PHILLIP L (OD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:L
Last Name:ERNZEN
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 1:8803 E CHURCHILL CIR
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-4441
Mailing Address - Country:US
Mailing Address - Phone:316-636-4059
Mailing Address - Fax:
Practice Address - Street 1:321 S HILLSIDE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67211-2130
Practice Address - Country:US
Practice Address - Phone:316-685-1898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS971-2152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS10090610AMedicaid
KS10090610AMedicaid
KS005-248Medicare ID - Type Unspecified