Provider Demographics
NPI:1710049085
Name:BASHORE, MARK ANDREW (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANDREW
Last Name:BASHORE
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 1:6380 N RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:OH
Mailing Address - Zip Code:44057-2548
Mailing Address - Country:US
Mailing Address - Phone:440-428-2172
Mailing Address - Fax:440-428-8677
Practice Address - Street 1:6380 N RIDGE RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:OH
Practice Address - Zip Code:44057-2548
Practice Address - Country:US
Practice Address - Phone:440-428-2172
Practice Address - Fax:440-428-8677
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4001T169152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHU31414Medicare UPIN
OH0708342Medicare PIN