Provider Demographics
NPI:1447504519
Name:STEPHEN T BASIC III OD AND ASSOCIATES PLLC
Entity type:Organization
Organization Name:STEPHEN T BASIC III OD AND ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:BASIC
Authorized Official - Suffix:III
Authorized Official - Credentials:OD
Authorized Official - Phone:434-409-2396
Mailing Address - Street 1:106 VILLAGE CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22903-4027
Mailing Address - Country:US
Mailing Address - Phone:434-409-2396
Mailing Address - Fax:
Practice Address - Street 1:1114 EMMET ST N STE D
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-4841
Practice Address - Country:US
Practice Address - Phone:434-971-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-29
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001252152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty