Provider Demographics
NPI:1184666422
Name:GUSTAFSON, PAUL L (OD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:L
Last Name:GUSTAFSON
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 1:543 S DAVID ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-3196
Mailing Address - Country:US
Mailing Address - Phone:307-237-9494
Mailing Address - Fax:307-237-1370
Practice Address - Street 1:543 S DAVID ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-3196
Practice Address - Country:US
Practice Address - Phone:307-237-9494
Practice Address - Fax:307-237-1370
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY267T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY115863500Medicaid
WYW4502373Medicare ID - Type Unspecified
WY115863500Medicaid