Healthcare Provider Details

I. General information

NPI: 1477511806
Provider Name (Legal Business Name): AMITABH K. BHARADWAJ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 06/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 TARA HILLS DR STE H
PINOLE CA
94564-2532
US

IV. Provider business mailing address

1320 TARA HILLS DR STE H
PINOLE CA
94564-2532
US

V. Phone/Fax

Practice location:
  • Phone: 510-724-1100
  • Fax: 510-724-1104
Mailing address:
  • Phone: 510-724-1100
  • Fax: 510-724-1104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberA101201
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: