Provider Demographics
NPI:1952370926
Name:FLYNN, PHILIP DUNNE IV (OD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:DUNNE
Last Name:FLYNN
Suffix:IV
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 1:2757 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2037
Mailing Address - Country:US
Mailing Address - Phone:803-799-7358
Mailing Address - Fax:803-779-3719
Practice Address - Street 1:2757 LAUREL ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2037
Practice Address - Country:US
Practice Address - Phone:803-799-7358
Practice Address - Fax:803-779-3719
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1250152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCU91386OtherNSC
SCD12500Medicaid
SC0239370001OtherDMEPO
SC0239370001Medicare NSC
SCU91386Medicare UPIN
SCD12500Medicaid