Provider Demographics
NPI:1770848384
Name:BASTIAN, DANIEL ARTHUR (OD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:ARTHUR
Last Name:BASTIAN
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 1:12 REVERE PL
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-3903
Mailing Address - Country:US
Mailing Address - Phone:508-517-0865
Mailing Address - Fax:
Practice Address - Street 1:940 BELMONT ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5596
Practice Address - Country:US
Practice Address - Phone:508-583-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-10
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002619152W00000X
MA4921152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist