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General NPI Number Information
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NPI Number | 1639148554
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Entity Type | Individual
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Provider Name | GARY BODOFSKY O.D.
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Gender | Male
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Dates
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Enumeration Date | 03/14/2006
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Last Update Date | 11/05/2015
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Provider Practice Location Address
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Address Line | 2014 HIGHWAY 17 N
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City | SURFSIDE BEACH
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State | SC
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Zip | 29575-6072
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Country | US
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Telephone | 843-238-2020
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Fax | 843-238-4443
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Provider Business Mailing Address
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Address Line | 2014 HIGHWAY 17 N
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City | SURFSIDE BEACH
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State | SC
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Zip | 29575-6072
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Country | US
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Telephone | 843-238-2020
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Fax | 843-238-4443
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 764
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License Number State | SC
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