Provider Demographics
NPI:1669465092
Name:HAAS, THERESA J (OD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:J
Last Name:HAAS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E 18TH ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-4616
Mailing Address - Country:US
Mailing Address - Phone:307-634-4232
Mailing Address - Fax:307-778-8429
Practice Address - Street 1:400 E 18TH ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-4616
Practice Address - Country:US
Practice Address - Phone:307-634-4232
Practice Address - Fax:307-778-8429
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2008-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY238T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY36203OtherDAVIS VISION
WY410041316OtherRAIL ROAD MEDICARE
WY307865OtherBLUE CROSS BLUE SHEILD
WY114039600Medicaid
WY307865OtherBLUE CROSS BLUE SHEILD
WYU70561Medicare UPIN