Provider Demographics
NPI:1700802840
Name:VESTER, DICK L (OD)
Entity type:Individual
Prefix:DR
First Name:DICK
Middle Name:L
Last Name:VESTER
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 1:425 PINE ST
Mailing Address - Street 2:
Mailing Address - City:WALLACE
Mailing Address - State:ID
Mailing Address - Zip Code:83873-2256
Mailing Address - Country:US
Mailing Address - Phone:208-752-2020
Mailing Address - Fax:208-556-7971
Practice Address - Street 1:425 PINE ST
Practice Address - Street 2:
Practice Address - City:WALLACE
Practice Address - State:ID
Practice Address - Zip Code:83873-2256
Practice Address - Country:US
Practice Address - Phone:208-752-2020
Practice Address - Fax:208-556-7971
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID0640152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000783200Medicaid
ID1591309Medicare PIN
6056240002Medicare NSC
ID000783200Medicaid