Provider Demographics
NPI:1255523254
Name:HARTLEY, JONATHAN (OD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:HARTLEY
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:PO BOX 2810
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-2810
Mailing Address - Country:US
Mailing Address - Phone:307-587-4206
Mailing Address - Fax:307-587-5539
Practice Address - Street 1:620 19TH ST
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-3305
Practice Address - Country:US
Practice Address - Phone:307-587-4206
Practice Address - Fax:307-587-5539
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY312T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY315337OtherBCBS
WY315337OtherBCBS