Provider Demographics
NPI:1891850707
Name:GILLETTE OPTOMETRIC CLINIC PC
Entity Type:Organization
Organization Name:GILLETTE OPTOMETRIC CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:L
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:307-682-2020
Mailing Address - Street 1:609 4J CT
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716-4135
Mailing Address - Country:US
Mailing Address - Phone:307-682-2020
Mailing Address - Fax:307-682-5656
Practice Address - Street 1:609 4J CT
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-4135
Practice Address - Country:US
Practice Address - Phone:307-682-2020
Practice Address - Fax:307-682-5656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY93-T152W00000X
WY142-T152WC0802X
WY288-T152WC0802X
WY263-T152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY103952100Medicaid
WY1659399376OtherROBERT MILLS, OD
WY1972537561OtherROGER JORDAN, OD
WY1023035854OtherDANA MCDERMOTT, OD
WI103718800Medicaid
WY11504720Medicaid
WY11903420Medicaid
WY1265466320OtherJOSEPH MAYCOCK, OD
WYU10226Medicare UPIN
WY1659399376OtherROBERT MILLS, OD
WYW9902Medicare ID - Type UnspecifiedJOSEPH MAYCOCK, OD
WYU98131Medicare UPIN
WY11504720Medicaid
WYW301430Medicare ID - Type UnspecifiedROBERT MILLS, OD
WY11903420Medicaid
WY1023035854OtherDANA MCDERMOTT, OD
WYU80357Medicare UPIN