Provider Demographics
NPI:1780069401
Name:WHETTEN, IVAN RUSSELL (OD)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:RUSSELL
Last Name:WHETTEN
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 1:2624 COMMERICAL WAY STE B
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-4769
Mailing Address - Country:US
Mailing Address - Phone:307-382-3753
Mailing Address - Fax:
Practice Address - Street 1:2624 COMMERCIAL WAY
Practice Address - Street 2:STE B
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-4769
Practice Address - Country:US
Practice Address - Phone:307-382-3753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-23
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY400T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist