Provider Demographics
NPI:1720036759
Name:DUBIN, PETER CHARLES (OD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:CHARLES
Last Name:DUBIN
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 1:201 EDDIE CHASTEEN DR
Mailing Address - Street 2:
Mailing Address - City:WALTERBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29488-5728
Mailing Address - Country:US
Mailing Address - Phone:843-893-2504
Mailing Address - Fax:843-549-0104
Practice Address - Street 1:201 EDDIE CHASTEEN DR
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-5728
Practice Address - Country:US
Practice Address - Phone:843-549-2015
Practice Address - Fax:843-549-0104
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC925152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD09257Medicaid
SC141697973OtherVISION SERVICE PLAN
SC141697973OtherBLUE CROSS BLUE SHIELD
SC141697973OtherVISION SERVICE PLAN
SCT651304800Medicare PIN