Provider Demographics
NPI:1023124989
Name:GWALTNEY, JORDAN E (OD)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:E
Last Name:GWALTNEY
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 1:2520 N 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:DODGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67801-2315
Mailing Address - Country:US
Mailing Address - Phone:620-227-3071
Mailing Address - Fax:620-227-6911
Practice Address - Street 1:2520 N 14TH AVE
Practice Address - Street 2:
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801-2315
Practice Address - Country:US
Practice Address - Phone:620-227-3071
Practice Address - Fax:620-227-6911
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1744152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS0333300001Medicare NSC