Healthcare Provider Details

I. General information

NPI: 1407812027
Provider Name (Legal Business Name): DAVID CARLYLE ELDRED O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2006
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2029 BLUEGRASS CIR
CHEYENNE WY
82009-7368
US

IV. Provider business mailing address

2029 BLUEGRASS CIR
CHEYENNE WY
82009-7368
US

V. Phone/Fax

Practice location:
  • Phone: 307-638-2020
  • Fax:
Mailing address:
  • Phone: 307-638-2020
  • Fax: 307-634-0939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number250-T
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: