Provider Demographics
NPI:1114142007
Name:BASILE, ROBERTA (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERTA
Middle Name:
Last Name:BASILE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 E CLAREMONT DR
Mailing Address - Street 2:
Mailing Address - City:VOORHEESVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12186-9103
Mailing Address - Country:US
Mailing Address - Phone:518-765-7986
Mailing Address - Fax:
Practice Address - Street 1:65 E CLAREMONT DR
Practice Address - Street 2:
Practice Address - City:VOORHEESVILLE
Practice Address - State:NY
Practice Address - Zip Code:12186-9103
Practice Address - Country:US
Practice Address - Phone:518-765-7986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYT004645152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist