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General NPI Number Information
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NPI Number | 1447504519
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Entity Type | Organization
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Legal Business Name | STEPHEN T BASIC III OD AND ASSOCIATES PLLC
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Dates
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Enumeration Date | 10/29/2012
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Last Update Date | 12/18/2012
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Provider Practice Location Address
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Address Line | 1114 EMMET ST N STE D
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City | CHARLOTTESVILLE
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State | VA
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Zip | 22903-4841
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Country | US
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Telephone | 434-971-2020
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Fax |
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Provider Business Mailing Address
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Address Line | 106 VILLAGE CT
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City | CHARLOTTESVILLE
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State | VA
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Zip | 22903-4027
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Country | US
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Telephone | 434-409-2396
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. STEPHEN THOMAS BASIC III
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Credential | O.D.
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Telephone | 434-409-2396
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 0618001252
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License Number State | VA
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