Provider Demographics
NPI:1174526461
Name:SUBER, WALTER J SR (DPM)
Entity type:Individual
Prefix:MR
First Name:WALTER
Middle Name:J
Last Name:SUBER
Suffix:SR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12407
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29504-2407
Mailing Address - Country:US
Mailing Address - Phone:843-662-6781
Mailing Address - Fax:843-662-6720
Practice Address - Street 1:514 S DARGAN ST
Practice Address - Street 2:STE F
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2552
Practice Address - Country:US
Practice Address - Phone:843-662-6781
Practice Address - Fax:843-662-6720
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC00036213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC480026354OtherR.R. MEDICARE
SCPDO369Medicaid
SC480026354OtherR.R. MEDICARE
SCU25104Medicare UPIN
SC20-2414588OtherEIN