Healthcare Provider Details

I. General information

NPI: 1639148554
Provider Name (Legal Business Name): GARY BODOFSKY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 11/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2014 HIGHWAY 17 N
SURFSIDE BEACH SC
29575-6072
US

IV. Provider business mailing address

2014 HIGHWAY 17 N
SURFSIDE BEACH SC
29575-6072
US

V. Phone/Fax

Practice location:
  • Phone: 843-238-2020
  • Fax: 843-238-4443
Mailing address:
  • Phone: 843-238-2020
  • Fax: 843-238-4443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number764
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: