Provider Demographics
NPI:1821181892
Name:BASTAICH, YOLANDA A (OD)
Entity Type:Individual
Prefix:DR
First Name:YOLANDA
Middle Name:A
Last Name:BASTAICH
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 1:104 LINCOLN AVE.
Mailing Address - Street 2:
Mailing Address - City:CHARLEROI
Mailing Address - State:PA
Mailing Address - Zip Code:15022
Mailing Address - Country:US
Mailing Address - Phone:724-518-6263
Mailing Address - Fax:
Practice Address - Street 1:WAL-MART VISION CENTER
Practice Address - Street 2:900 SUMMIT RIDGE PLAZA
Practice Address - City:MT. PLEASANT
Practice Address - State:PA
Practice Address - Zip Code:15666
Practice Address - Country:US
Practice Address - Phone:724-542-9792
Practice Address - Fax:724-542-9793
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOE-008327-T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA52381OtherDAVIS VISION
PA35034OtherAVESIS
PA001788218OtherPROMISE
PA01788218Medicaid
PABA673704OtherBLUE CROSS BLUE SHIELD
PA251841812OtherNVA
PA27730OtherMEDICAL EYE SERVICES
PA08345OtherSPECTERA
PA52381OtherDAVIS VISION
PAU77385Medicare UPIN