Provider Demographics
NPI:1780765289
Name:BASS, ERIC (OD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:
Last Name:BASS
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 1:15068 GOLDENWEST ST
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-6152
Mailing Address - Country:US
Mailing Address - Phone:714-898-5631
Mailing Address - Fax:877-539-8668
Practice Address - Street 1:15068 GOLDENWEST ST
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-6152
Practice Address - Country:US
Practice Address - Phone:714-898-5631
Practice Address - Fax:714-898-6576
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8249T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0082490Medicaid
CAOP8249AOtherPPIN
CAOP8249AOtherPPIN