Provider Demographics
NPI:1124284997
Name:DESPAIN, JACOB G (OD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:G
Last Name:DESPAIN
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 1:1708 STAMPEDE AVE
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-4829
Mailing Address - Country:US
Mailing Address - Phone:307-587-2404
Mailing Address - Fax:307-527-7368
Practice Address - Street 1:1708 STAMPEDE AVE
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-4829
Practice Address - Country:US
Practice Address - Phone:307-587-2404
Practice Address - Fax:307-527-7368
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-31
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60035926152W00000X
WY327T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY135237700Medicaid
WYW25396OtherPTAN