Healthcare Provider Details

I. General information

NPI: 1568457414
Provider Name (Legal Business Name): WESLEY VORPAHL OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 06/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 STATE ST #G-770
SALEM OR
97301-5861
US

IV. Provider business mailing address

3400 STATE ST #G-770
SALEM OR
97301-5861
US

V. Phone/Fax

Practice location:
  • Phone: 503-585-6700
  • Fax: 503-585-3315
Mailing address:
  • Phone: 503-585-6700
  • Fax: 503-585-3315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1666AT
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: