Provider Demographics
NPI:1295808848
Name:BASTHOLM, THOMAS GEORGE (OD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:GEORGE
Last Name:BASTHOLM
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 1:1540 SAVANNAH RD
Mailing Address - Street 2:
Mailing Address - City:LEWES
Mailing Address - State:DE
Mailing Address - Zip Code:19958-1682
Mailing Address - Country:US
Mailing Address - Phone:302-645-2020
Mailing Address - Fax:302-645-2223
Practice Address - Street 1:1540 SAVANNAH RD
Practice Address - Street 2:
Practice Address - City:LEWES
Practice Address - State:DE
Practice Address - Zip Code:19958-1682
Practice Address - Country:US
Practice Address - Phone:302-645-2020
Practice Address - Fax:302-645-2223
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEDEI30001133152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE118980Medicare ID - Type Unspecified
DET26919Medicare UPIN