Provider Demographics
NPI:1275133399
Name:BODALIA, BHAVISH D
Entity Type:Individual
Prefix:
First Name:BHAVISH
Middle Name:D
Last Name:BODALIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 DUVAL CT
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-2087
Mailing Address - Country:US
Mailing Address - Phone:312-804-1657
Mailing Address - Fax:630-312-8921
Practice Address - Street 1:4 DUVAL CT
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60490-2087
Practice Address - Country:US
Practice Address - Phone:312-804-1657
Practice Address - Fax:630-312-8921
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.287731183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist