Provider Demographics
NPI:1699829382
Name:CASPER VISION CENTER PC
Entity Type:Organization
Organization Name:CASPER VISION CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:L
Authorized Official - Last Name:GUSTAFSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:307-237-9494
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY125T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY100076400Medicaid
WY115863500Medicaid
WYW4502373Medicare ID - Type UnspecifiedDAVID R. CARLSON
WYW4502373Medicare ID - Type UnspecifiedPAUL L. GUSTAFSON
WY0679730001Medicare NSC
WY100076400Medicaid
WIU28409Medicare UPIN