Provider Demographics
NPI:1477518116
Name:THADDEUS W BARTLES OD PC
Entity Type:Organization
Organization Name:THADDEUS W BARTLES OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THADDEUS
Authorized Official - Middle Name:W
Authorized Official - Last Name:BARTLES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:860-582-0702
Mailing Address - Street 1:271 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-3962
Mailing Address - Country:US
Mailing Address - Phone:860-582-0702
Mailing Address - Fax:860-314-0263
Practice Address - Street 1:271 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-3962
Practice Address - Country:US
Practice Address - Phone:860-582-0702
Practice Address - Fax:860-314-0263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT790152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4021549Medicaid
CT4021549Medicaid
C00679Medicare PIN