Provider Demographics
NPI:1265625297
Name:WYOMING EYE & LASER INC.
Entity type:Organization
Organization Name:WYOMING EYE & LASER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:ALFONSO
Authorized Official - Last Name:AVILES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-371-4294
Mailing Address - Street 1:1005 COLLEGE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-2266
Mailing Address - Country:US
Mailing Address - Phone:307-371-4294
Mailing Address - Fax:307-857-5215
Practice Address - Street 1:1005 COLLEGE VIEW DR
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-2266
Practice Address - Country:US
Practice Address - Phone:307-371-4294
Practice Address - Fax:307-857-5215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-23
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7754A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1205837010Medicaid
WY21542Medicare PIN
AZ103911Medicare UPIN