Basic Information
| Provider Information | |||||||||
| NPI: | 1588729099 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TABASSI | ||||||||
| FirstName: | BITA | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 175 E HOUSTON ST | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782052255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105246663 | ||||||||
| FaxNumber: | 2105246587 | ||||||||
| Practice Location | |||||||||
| Address1: | 7815 PRESTON HWY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402193140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5029662020 | ||||||||
| FaxNumber: | 5029662099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2006 | ||||||||
| LastUpdateDate: | 07/10/2014 | ||||||||
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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 | 1528DT | KY | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 77000586 | 05 | KY | MEDICAID |