Provider Demographics
NPI:1295791598
Name:DIANA, PERIN W JR (MD)
Entity type:Individual
Prefix:DR
First Name:PERIN
Middle Name:W
Last Name:DIANA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:55 MERIDEN AVE
Mailing Address - Street 2:STE 2D
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-3235
Mailing Address - Country:US
Mailing Address - Phone:843-726-6509
Mailing Address - Fax:843-726-6809
Practice Address - Street 1:1000 PINE STREET
Practice Address - Street 2:
Practice Address - City:VARNVILLE
Practice Address - State:SC
Practice Address - Zip Code:29944-0969
Practice Address - Country:US
Practice Address - Phone:803-943-5228
Practice Address - Fax:803-943-4591
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC20809207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0365Medicaid
SC570669239-001OtherBLUE CROSS
SCT49310Medicaid
SC570669239-002OtherBLUE CHOICE
SC570669239-001OtherBLUE CROSS
SC4004Medicare ID - Type UnspecifiedMEDICARE GROUP #