Provider Demographics
NPI:1316933989
Name:KOZEL-DIAMOND, SANDRA L (OD)
Entity type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:L
Last Name:KOZEL-DIAMOND
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 BUR OAK CT
Mailing Address - Street 2:APT D
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-5273
Mailing Address - Country:US
Mailing Address - Phone:843-333-5436
Mailing Address - Fax:
Practice Address - Street 1:4000 HIGHWAY 9 E
Practice Address - Street 2:SUITE 260
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566-7833
Practice Address - Country:US
Practice Address - Phone:843-390-0058
Practice Address - Fax:843-390-0999
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1241152W00000X
SC1409152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD14090Medicaid
SCD14090Medicaid
SC5814320001Medicare NSC
SCV05669Medicare UPIN