Provider Demographics
NPI:1629047758
Name:VANDERVORT, CHARLES R (OD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:VANDERVORT
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 1:665 UINTA DR
Mailing Address - Street 2:
Mailing Address - City:GREEN RIVER
Mailing Address - State:WY
Mailing Address - Zip Code:82935-5031
Mailing Address - Country:US
Mailing Address - Phone:307-875-4538
Mailing Address - Fax:307-875-8997
Practice Address - Street 1:665 UINTA DR
Practice Address - Street 2:
Practice Address - City:GREEN RIVER
Practice Address - State:WY
Practice Address - Zip Code:82935-5031
Practice Address - Country:US
Practice Address - Phone:307-875-4538
Practice Address - Fax:307-875-8997
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY101T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY114697100Medicaid
WY001798001OtherBLUE CROSS BLUE SHIELD
WY410040553OtherRAILROAD MEDICARE
WY410040553OtherRAILROAD MEDICARE
WYW301158Medicare ID - Type Unspecified