Provider Demographics
NPI:1154314144
Name:BARTLES, THADDEUS W (OD)
Entity Type:Individual
Prefix:
First Name:THADDEUS
Middle Name:W
Last Name:BARTLES
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-3901
Mailing Address - Country:US
Mailing Address - Phone:860-582-0702
Mailing Address - Fax:
Practice Address - Street 1:271 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-3901
Practice Address - Country:US
Practice Address - Phone:860-582-0702
Practice Address - Fax:860-314-0263
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2010-08-13
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-04-12
Provider Licenses
StateLicense IDTaxonomies
CT790152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0452540001OtherMEDICARE DMERC
CT004021549Medicaid
CT004021549Medicaid
410000464Medicare PIN
T23089Medicare UPIN