Provider Demographics
NPI:1144270398
Name:GOMAN BASKIN, ELINA (OD)
Entity type:Individual
Prefix:
First Name:ELINA
Middle Name:
Last Name:GOMAN BASKIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 CASTLE DR
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:MA
Mailing Address - Zip Code:02067-2442
Mailing Address - Country:US
Mailing Address - Phone:781-818-4118
Mailing Address - Fax:781-818-4118
Practice Address - Street 1:50 MAUDE ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02908-4325
Practice Address - Country:US
Practice Address - Phone:401-351-5664
Practice Address - Fax:401-456-5726
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIODTA00493152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI31251-6OtherBLUE SHIELD
RI412591OtherBLUECHIP
RIEG59603Medicaid
RI412591OtherBLUECHIP
RI31251-6OtherBLUE SHIELD