Provider Demographics
NPI:1548789654
Name:SIDHOM, BASANT T (OD)
Entity Type:Individual
Prefix:
First Name:BASANT
Middle Name:T
Last Name:SIDHOM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1565 POST RD UNIT 5
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02888-5949
Mailing Address - Country:US
Mailing Address - Phone:401-472-9424
Mailing Address - Fax:401-472-9423
Practice Address - Street 1:1565 POST RD UNIT 5
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02888-5949
Practice Address - Country:US
Practice Address - Phone:603-418-4956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-11
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5231152W00000X
RIODTG00655152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty