Provider Demographics
NPI:1568457414
Name:VORPAHL, WESLEY (OD)
Entity Type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:
Last Name:VORPAHL
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 1:3400 STATE ST
Mailing Address - Street 2:#G-770
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-5861
Mailing Address - Country:US
Mailing Address - Phone:503-585-6700
Mailing Address - Fax:503-585-3315
Practice Address - Street 1:3400 STATE ST
Practice Address - Street 2:#G-770
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-5861
Practice Address - Country:US
Practice Address - Phone:503-585-6700
Practice Address - Fax:503-585-3315
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-16
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1666AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR272484Medicaid
ORR0000PHDPWMedicare PIN
OR272484Medicaid