Provider Demographics
NPI:1477547628
Name:BASHAM, BRADLEY S (OD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:S
Last Name:BASHAM
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 1:1515 E PAULDING RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46816-1252
Mailing Address - Country:US
Mailing Address - Phone:260-744-2273
Mailing Address - Fax:260-744-4555
Practice Address - Street 1:1515 E PAULDING RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46816-1252
Practice Address - Country:US
Practice Address - Phone:260-744-2273
Practice Address - Fax:260-744-4555
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002201152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100053350Medicaid
IN100053350AMedicaid
IN100053350AMedicaid
IN0258750005Medicare NSC
IN0258750001Medicare NSC
IN669220016Medicare PIN
INT34785Medicare UPIN
IN100053350AMedicaid