Provider Demographics
NPI:1851361059
Name:BAUSBACK, HENRY (OD)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:
Last Name:BAUSBACK
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 1:6002 POINTE WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-5531
Mailing Address - Country:US
Mailing Address - Phone:941-792-2020
Mailing Address - Fax:941-792-9257
Practice Address - Street 1:6002 POINTE WEST BLVD
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-5531
Practice Address - Country:US
Practice Address - Phone:941-792-2020
Practice Address - Fax:941-792-9257
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002622A152W00000X
FLOPC-5052152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100376610Medicaid
IN565740DMedicare PIN
IN217230IIIMedicare ID - Type Unspecified
IN100376610Medicaid