Provider Demographics
NPI:1942518774
Name:OBRADOVIC, IVANA (OD)
Entity Type:Individual
Prefix:
First Name:IVANA
Middle Name:
Last Name:OBRADOVIC
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3176 S UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-3002
Mailing Address - Country:US
Mailing Address - Phone:954-431-2020
Mailing Address - Fax:954-435-7124
Practice Address - Street 1:2460 INDIA HOOK RD STE 206
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-3578
Practice Address - Country:US
Practice Address - Phone:803-985-2020
Practice Address - Fax:803-985-2021
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-14
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2256152W00000X
FLOPC 4521152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD22562Medicaid
FL003809600Medicaid
GA003110735AMedicaid