Healthcare Provider Details

I. General information

NPI: 1184666422
Provider Name (Legal Business Name): PAUL L. GUSTAFSON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 10/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

543 S DAVID ST
CASPER WY
82601-3196
US

IV. Provider business mailing address

543 S DAVID ST
CASPER WY
82601-3196
US

V. Phone/Fax

Practice location:
  • Phone: 307-237-9494
  • Fax: 307-237-1370
Mailing address:
  • Phone: 307-237-9494
  • Fax: 307-237-1370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number267T
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: