Healthcare Provider Details

I. General information

NPI: 1154314144
Provider Name (Legal Business Name): THADDEUS W BARTLES O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 08/13/2010
Certification Date:
Deactivation Date: 03/27/2006
Reactivation Date: 04/12/2006

III. Provider practice location address

271 FARMINGTON AVE
BRISTOL CT
06010-3901
US

IV. Provider business mailing address

271 FARMINGTON AVE
BRISTOL CT
06010-3901
US

V. Phone/Fax

Practice location:
  • Phone: 860-582-0702
  • Fax: 860-314-0263
Mailing address:
  • Phone: 860-582-0702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number790
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: