MEDICARE: DR. TED MACK SEYMORE O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	5455TG	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	83043E	OTHER	TX	BCBS PROVIDER #
2	83212V	OTHER	TX	BCBS PROVIDER #
3	00E11Z	OTHER	TX	BCBS PROVIDER #

General Provider Information

NPI Number	:	1770694549
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TED MACK SEYMORE O.D.

Provider Business Mailing Address
First Line	:	2311 SCURRY ST
Second Line	:
City	:	BIG SPRING
State	:	TX
Zip	:	79720-5552
Country	:	US
Telephone Number	:	432-267-4854
Fax Number	:

Provider Business Practice Location Address
First Line	:	2311 SCURRY ST
Second Line	:
City	:	BIG SPRING
State	:	TX
Zip	:	79720-5552
Country	:	US
Telephone Number	:	432-267-4854
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	07/08/2007

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