Provider Demographics
NPI:1740406214
Name:CUSTER, LAWRENCE RAYMOND (OD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:RAYMOND
Last Name:CUSTER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 50864
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-0015
Mailing Address - Country:US
Mailing Address - Phone:843-444-0090
Mailing Address - Fax:843-444-0377
Practice Address - Street 1:1512 COASTAL GRAND CIR
Practice Address - Street 2:C330
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-0015
Practice Address - Country:US
Practice Address - Phone:843-444-0090
Practice Address - Fax:843-444-0377
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC1237152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSC1237OtherEYEMED VISION CARE
SC20439Medicare UPIN