Healthcare Provider Details

I. General information

NPI: 1952370926
Provider Name (Legal Business Name): PHILIP DUNNE FLYNN IV OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 09/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2757 LAUREL ST
COLUMBIA SC
29204-2037
US

IV. Provider business mailing address

2757 LAUREL ST
COLUMBIA SC
29204-2037
US

V. Phone/Fax

Practice location:
  • Phone: 803-799-7358
  • Fax: 803-779-3719
Mailing address:
  • Phone: 803-799-7358
  • Fax: 803-779-3719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1250
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: