Provider Demographics
NPI:1235164864
Name:MEDLIN, DIANA N (OD, MH, PDH)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:N
Last Name:MEDLIN
Suffix:
Gender:F
Credentials:OD, MH, PDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 W SHIPYARD RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-6658
Mailing Address - Country:US
Mailing Address - Phone:843-971-8030
Mailing Address - Fax:
Practice Address - Street 1:2070 SAM RITTENBERG BLVD STE 412
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-4605
Practice Address - Country:US
Practice Address - Phone:843-556-8844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC989152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDP9891Medicaid
SCU26900Medicare UPIN