Individual
CHARLES R. VANDERVORT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
O.D.
Contact information
Practice address
665 UINTA DR, GREEN RIVER, WY 82935-5031
(307) 875-4538
(307) 875-8997
Mailing address
665 UINTA DR, GREEN RIVER, WY 82935-5031
(307) 875-4538
(307) 875-8997
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
101T
WY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
001798001
BLUE CROSS BLUE SHIELD
WY
05
—
114697100
—
WY
01
—
410040553
RAILROAD MEDICARE
WY
Enumeration date
03/14/2006
Last updated
09/17/2012
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