Provider Demographics
NPI:1821072042
Name:WORTHAM, ROSS C (OD)
Entity Type:Individual
Prefix:DR
First Name:ROSS
Middle Name:C
Last Name:WORTHAM
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 1:400 E ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-4413
Mailing Address - Country:US
Mailing Address - Phone:307-856-6531
Mailing Address - Fax:307-856-1306
Practice Address - Street 1:400 E ADAMS AVE
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-4413
Practice Address - Country:US
Practice Address - Phone:307-856-6531
Practice Address - Fax:307-856-1306
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYT197152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY102280600Medicaid
U16522Medicare UPIN
WY102280600Medicaid
WY0902350001Medicare NSC