Provider Demographics
NPI:1487753950
Name:NETT, JEREMY T (OD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:T
Last Name:NETT
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 1:400 E 18TH ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001
Mailing Address - Country:US
Mailing Address - Phone:307-634-4232
Mailing Address - Fax:307-778-8429
Practice Address - Street 1:400 E 18TH ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-4616
Practice Address - Country:US
Practice Address - Phone:307-634-4232
Practice Address - Fax:307-778-8429
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2008-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY308T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY123387400Medicaid
WY123387400Medicaid
WYW21194Medicare PIN