Healthcare Provider Details

I. General information

NPI: 1699829382
Provider Name (Legal Business Name): CASPER VISION CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 01/02/2013
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 Number125T
License Number StateWY

VIII. Authorized Official

Name: DR. PAUL L GUSTAFSON
Title or Position: OPTOMETRIST
Credential: OD
Phone: 307-237-9494