Provider Demographics
NPI:1548491640
Name:BASTIDAS, FABIAN ROBERTO (LDO)
Entity type:Individual
Prefix:MR
First Name:FABIAN
Middle Name:ROBERTO
Last Name:BASTIDAS
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 SE OCEAN BLVD
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-2214
Mailing Address - Country:US
Mailing Address - Phone:772-221-8878
Mailing Address - Fax:772-221-8878
Practice Address - Street 1:33 SE OCEAN BLVD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2214
Practice Address - Country:US
Practice Address - Phone:772-221-8878
Practice Address - Fax:772-221-8878
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO3354156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician