Provider Demographics
NPI:1003870890
Name:BHARADIA, MOHAMED SHABIR (OD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMED
Middle Name:SHABIR
Last Name:BHARADIA
Suffix:
Gender:M
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:PO BOX 21203
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29221-1203
Mailing Address - Country:US
Mailing Address - Phone:803-750-4949
Mailing Address - Fax:803-750-7172
Practice Address - Street 1:1326 BUSH RIVER RD
Practice Address - Street 2:AT WALMART VISION CENTER
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-6804
Practice Address - Country:US
Practice Address - Phone:803-750-4949
Practice Address - Fax:803-750-7172
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1047152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD10478Medicaid
SCU29011Medicare UPIN
SCU290110281Medicare PIN