Provider Demographics
NPI:1932108677
Name:CANESTRINI, RICHARD P (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:P
Last Name:CANESTRINI
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 1:544 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-6346
Mailing Address - Country:US
Mailing Address - Phone:307-382-3937
Mailing Address - Fax:307-382-2918
Practice Address - Street 1:544 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-6346
Practice Address - Country:US
Practice Address - Phone:307-382-3937
Practice Address - Fax:307-382-2918
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY161T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY104186000Medicaid
WY104186000Medicaid
WY4978190001Medicare NSC
WYW307686Medicare PIN
WY307686Medicare PIN
WY410036451Medicare PIN