Provider Demographics
NPI:1881680270
Name:GOERTZ, AMY RENEE (OD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:RENEE
Last Name:GOERTZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11621 W 17TH ST N
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-6968
Mailing Address - Country:US
Mailing Address - Phone:316-260-9736
Mailing Address - Fax:316-832-0029
Practice Address - Street 1:12111 W MAPLE ST STE 125
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67235-8756
Practice Address - Country:US
Practice Address - Phone:316-832-0088
Practice Address - Fax:316-832-0029
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1683152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200277350AMedicaid
KS651042Medicare PIN
KS200277350AMedicaid