Provider Demographics
NPI:1912975855
Name:GILLOGLY, DANIEL A (OD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:A
Last Name:GILLOGLY
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 1:1851 N WEBB RD
Mailing Address - Street 2:ATTN FLR2
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-3413
Mailing Address - Country:US
Mailing Address - Phone:316-636-2010
Mailing Address - Fax:316-858-3830
Practice Address - Street 1:1821 E MADISON AVE
Practice Address - Street 2:SUITE 1600
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-2357
Practice Address - Country:US
Practice Address - Phone:316-789-8383
Practice Address - Fax:316-789-0336
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1327-3152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100219560CMedicaid
KS410029920OtherRAILROAD MEDICARE
KSU12997Medicare UPIN
KS100219560CMedicaid