Provider Demographics
NPI:1073520805
Name:PAULATOS, SUMMER MOORER (OD)
Entity Type:Individual
Prefix:DR
First Name:SUMMER
Middle Name:MOORER
Last Name:PAULATOS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:SUMMER
Other - Middle Name:LEIGH
Other - Last Name:MOORER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:28 AVONDALE AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-7259
Mailing Address - Country:US
Mailing Address - Phone:843-763-3990
Mailing Address - Fax:
Practice Address - Street 1:1231 FOLLY RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-4105
Practice Address - Country:US
Practice Address - Phone:843-795-3400
Practice Address - Fax:843-795-3435
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1420152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD14205Medicaid
SC205268645OtherRR MEDICARE
SCAA15678582Medicare PIN