Provider Demographics
NPI:1780683698
Name:DIAMOND, JASON L (OD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:L
Last Name:DIAMOND
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 1:3700 SAWTELL RD B
Mailing Address - Street 2:
Mailing Address - City:LITTLE RIVER
Mailing Address - State:SC
Mailing Address - Zip Code:29566-7873
Mailing Address - Country:US
Mailing Address - Phone:843-390-0058
Mailing Address - Fax:843-390-0999
Practice Address - Street 1:3700 SAWTELL RD
Practice Address - Street 2:SUITE B
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566-7873
Practice Address - Country:US
Practice Address - Phone:843-390-0058
Practice Address - Fax:843-390-9990
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1244152W00000X
SC1408152W00000X
NC2086152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD14081Medicaid
SCV05939Medicare UPIN
SCD14081Medicaid
SCV059398517Medicare PIN