Healthcare Provider Details

I. General information

NPI: 1942518774
Provider Name (Legal Business Name): IVANA OBRADOVIC O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2010
Last Update Date: 06/21/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2460 INDIA HOOK RD STE 206
ROCK HILL SC
29732-3578
US

IV. Provider business mailing address

3176 S UNIVERSITY DR
MIRAMAR FL
33025-3002
US

V. Phone/Fax

Practice location:
  • Phone: 803-985-2020
  • Fax: 803-985-2021
Mailing address:
  • Phone: 954-431-2020
  • Fax: 954-435-7124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2256
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC 4521
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: