Provider Demographics
NPI:1639148554
Name:BODOFSKY, GARY (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:BODOFSKY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2014 HIGHWAY 17 N
Mailing Address - Street 2:
Mailing Address - City:SURFSIDE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29575-6072
Mailing Address - Country:US
Mailing Address - Phone:843-238-2020
Mailing Address - Fax:843-238-4443
Practice Address - Street 1:2014 HIGHWAY 17 N
Practice Address - Street 2:
Practice Address - City:SURFSIDE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29575-6072
Practice Address - Country:US
Practice Address - Phone:843-238-2020
Practice Address - Fax:843-238-4443
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC764152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC571062888OtherUNITED HEALTH CARE
SC571062888OtherCIGNA, PPO
SCSC07890281OtherMEDICARE PTAN
SC571062888OtherAETNA
SCD00764Medicaid
SC571062888OtherBCBS OF SC
SC571062888OtherMEDCOST
SCSC07890281Medicare PIN
SC571062888OtherMEDCOST