Healthcare Provider Details

I. General information

NPI: 1407231897
Provider Name (Legal Business Name): DAVID SEABOLT II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2015
Last Update Date: 07/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3867 ROSWELL RD NE STE 100
ATLANTA GA
30342-4452
US

IV. Provider business mailing address

7610 OLD SADDLE RIDGE WAY
CUMMING GA
30028-8902
US

V. Phone/Fax

Practice location:
  • Phone: 678-904-5611
  • Fax:
Mailing address:
  • Phone: 678-887-5901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number02492
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: