Provider Demographics
NPI:1295875938
Name:BODKIN, DAVID BRADLEY (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:BRADLEY
Last Name:BODKIN
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 1:1296 LONG GROVE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-9462
Mailing Address - Country:US
Mailing Address - Phone:617-970-2252
Mailing Address - Fax:
Practice Address - Street 1:1296 LONG GROVE DR
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-9462
Practice Address - Country:US
Practice Address - Phone:617-970-2252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1461152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD14615Medicaid
AA22414340Medicare UPIN