Provider Demographics
NPI:1407994767
Name:SUBER, WALTER JOHN JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:JOHN
Last Name:SUBER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2755 S HIGHWAY 14
Mailing Address - Street 2:SUITE 2150
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29650-4902
Mailing Address - Country:US
Mailing Address - Phone:864-288-8118
Mailing Address - Fax:864-288-8113
Practice Address - Street 1:2755 S HIGHWAY 14
Practice Address - Street 2:SUITE 2150
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-4902
Practice Address - Country:US
Practice Address - Phone:864-288-8118
Practice Address - Fax:864-288-8113
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21476174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC21476OtherLICENSE
SC571106965OtherTAX ID
SC214761Medicaid
SCH321810281Medicare ID - Type Unspecified
SC21476OtherLICENSE