Basic Information
| Provider Information | |||||||||
| NPI: | 1861425035 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BASILE | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 888 WORCESTER ST | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | WELLESLEY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024823744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179646681 | ||||||||
| FaxNumber: | 3396862561 | ||||||||
| Practice Location | |||||||||
| Address1: | 888 WORCESTER ST | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | WELLESLEY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024823744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179646681 | ||||||||
| FaxNumber: | 3396862561 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 08/27/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 3573 | MA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 0356018 | 05 | MA | MEDICAID | 410045312 | 01 | MA | MEDICARE RAILROAD | OTHER | W15836 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER |