Provider Demographics
NPI:1063413318
Name:BOURLAND, WILLIAM BRUCE (OD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:BRUCE
Last Name:BOURLAND
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 1:701 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-3522
Mailing Address - Country:US
Mailing Address - Phone:307-789-8820
Mailing Address - Fax:307-789-8823
Practice Address - Street 1:701 FRONT ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-3522
Practice Address - Country:US
Practice Address - Phone:307-789-8820
Practice Address - Fax:307-789-8823
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY203T152W00000X
NM238152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY102083800Medicaid
4437740001OtherCIGNA/MEDICARE
830336991OtherAETNA
T74978Medicare UPIN
830336991OtherAETNA