Provider Demographics
NPI:1184633547
Name:BAUSCH, DANIEL EDWARD (OD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:EDWARD
Last Name:BAUSCH
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 1:289 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01103-1409
Mailing Address - Country:US
Mailing Address - Phone:413-734-8366
Mailing Address - Fax:413-739-5596
Practice Address - Street 1:289 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-1409
Practice Address - Country:US
Practice Address - Phone:413-734-8366
Practice Address - Fax:413-739-5596
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2337152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0326836Medicaid
MA54588OtherUPIN
MA54588OtherUPIN