Provider Demographics
NPI:1265468367
Name:BASS, THOMAS L (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:L
Last Name:BASS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4519 TILTON COURT
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907
Mailing Address - Country:US
Mailing Address - Phone:239-494-8777
Mailing Address - Fax:239-288-7139
Practice Address - Street 1:4519 TILTON COURT
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907
Practice Address - Country:US
Practice Address - Phone:239-494-8777
Practice Address - Fax:239-288-7139
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME66691208600000X, 2086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269332100Medicaid
FL269332100Medicaid
F90805Medicare UPIN