MEDICARE: DR. BRADLEY S BASHAM O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	18002201	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477547628
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRADLEY S BASHAM O.D.

Provider Business Mailing Address
First Line	:	1515 E PAULDING RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46816-1252
Country	:	US
Telephone Number	:	260-744-2273
Fax Number	:	260-744-4555

Provider Business Practice Location Address
First Line	:	1515 E PAULDING RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46816-1252
Country	:	US
Telephone Number	:	260-744-2273
Fax Number	:	260-744-4555

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/02/2005
Last Update Date	:	06/10/2015

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