Provider Demographics
NPI:1639262504
Name:OBSSUTH, GEORGE ALLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:ALLEN
Last Name:OBSSUTH
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:POST OFFICE BOX 1452
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82073-1452
Mailing Address - Country:US
Mailing Address - Phone:307-742-0674
Mailing Address - Fax:307-742-4498
Practice Address - Street 1:4308 EAST GRAND AVENUE
Practice Address - Street 2:
Practice Address - City:LAAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-5508
Practice Address - Country:US
Practice Address - Phone:307-755-0248
Practice Address - Fax:307-755-0276
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY213T152W00000X
CO99154399152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYU36139Medicare UPIN
WYW9917Medicare ID - Type UnspecifiedMEDICARE PSO