Provider Demographics
NPI:1184927105
Name:BASCOME, JOHN HARDY V (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:HARDY
Last Name:BASCOME
Suffix:V
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:H
Other - Last Name:BASCOME
Other - Suffix:V
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:2502 E OAKLAND PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33306-1601
Mailing Address - Country:US
Mailing Address - Phone:954-564-2020
Mailing Address - Fax:954-565-4671
Practice Address - Street 1:2502 E OAKLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1601
Practice Address - Country:US
Practice Address - Phone:954-564-2020
Practice Address - Fax:954-565-4671
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-14
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL004568152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008988600OtherMEDICAID GROUP
FL008992900Medicaid
FL008988600OtherMEDICAID GROUP