Provider Demographics
NPI:1093878670
Name:BASHOVER, MARK JOEL (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOEL
Last Name:BASHOVER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:845 NEWBURG AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-3107
Mailing Address - Country:US
Mailing Address - Phone:516-791-8254
Mailing Address - Fax:516-791-8254
Practice Address - Street 1:845 NEWBURG AVE
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-3107
Practice Address - Country:US
Practice Address - Phone:516-791-8254
Practice Address - Fax:516-791-8254
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV003332-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC47851Medicare UPIN
NY32475Medicare UPIN