Provider Demographics
NPI:1477511806
Name:BHARADWAJ, AMITABH K (MD)
Entity Type:Individual
Prefix:DR
First Name:AMITABH
Middle Name:K
Last Name:BHARADWAJ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1320 TARA HILLS DR STE H
Mailing Address - Street 2:
Mailing Address - City:PINOLE
Mailing Address - State:CA
Mailing Address - Zip Code:94564-2532
Mailing Address - Country:US
Mailing Address - Phone:510-724-1100
Mailing Address - Fax:510-724-1104
Practice Address - Street 1:1320 TARA HILLS DR STE H
Practice Address - Street 2:
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-2532
Practice Address - Country:US
Practice Address - Phone:510-724-1100
Practice Address - Fax:510-724-1104
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA101201207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ001976049Medicaid
I32718Medicare UPIN