Individual
DR. BRADLEY S BASHAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
O.D.
Contact information
Practice address
1515 E PAULDING RD, FORT WAYNE, IN 46816-1252
(260) 744-2273
(260) 744-4555
Mailing address
1515 E PAULDING RD, FORT WAYNE, IN 46816-1252
(260) 744-2273
(260) 744-4555
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
18002201
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100053350
—
IN
05
—
100053350A
—
IN
Enumeration date
09/02/2005
Last updated
06/10/2015
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