Provider Demographics
NPI:1598924581
Name:BOLDEN RAVENELL, TAMIKA M (DPM)
Entity Type:Individual
Prefix:DR
First Name:TAMIKA
Middle Name:M
Last Name:BOLDEN RAVENELL
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:TAMIKA
Other - Middle Name:M
Other - Last Name:BOLDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:PO BOX 783
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29465-0783
Mailing Address - Country:US
Mailing Address - Phone:916-215-1234
Mailing Address - Fax:843-606-2483
Practice Address - Street 1:180 WINGO WAY
Practice Address - Street 2:SUITE 201
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-1810
Practice Address - Country:US
Practice Address - Phone:843-856-5337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-04
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCPOD.607 POD213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP9889Medicaid
SCGP9889Medicaid