Provider Demographics
NPI:1457578080
Name:T J BAUER OD PC
Entity Type:Organization
Organization Name:T J BAUER OD PC
Other - Org Name:BAUER EYE CARE PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BAUER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:9709-927-2020
Mailing Address - Street 1:850 EAST VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:BASALT
Mailing Address - State:CO
Mailing Address - Zip Code:81621-7600
Mailing Address - Country:US
Mailing Address - Phone:970-927-2020
Mailing Address - Fax:970-927-2010
Practice Address - Street 1:850 EAST VALLEY RD
Practice Address - Street 2:
Practice Address - City:BASALT
Practice Address - State:CO
Practice Address - Zip Code:81621-7600
Practice Address - Country:US
Practice Address - Phone:970-927-2020
Practice Address - Fax:970-927-2010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1545152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOB4691Medicare PIN