Provider Demographics
NPI:1639219132
Name:BASS, LELAND (OD)
Entity Type:Individual
Prefix:
First Name:LELAND
Middle Name:
Last Name:BASS
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 1:9 W PUTNAM AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-5327
Mailing Address - Country:US
Mailing Address - Phone:203-552-6830
Mailing Address - Fax:
Practice Address - Street 1:9 W PUTNAM AVE
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-5327
Practice Address - Country:US
Practice Address - Phone:203-552-6830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2384152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTU76366Medicare UPIN