Provider Demographics
NPI:1689761249
Name:BASHOVER, MATTHEW (OD)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:BASHOVER
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 1:6702 KINGSHOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-2923
Mailing Address - Country:US
Mailing Address - Phone:972-385-7050
Mailing Address - Fax:
Practice Address - Street 1:624 LINCOLN SQ
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76011-4896
Practice Address - Country:US
Practice Address - Phone:817-261-2020
Practice Address - Fax:817-261-2262
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3315-T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX35787OtherDAVIS VISION
TX093450702Medicaid
TX900917OtherBLOCK VISION
TX35787OtherDAVIS VISION