Healthcare Provider Details

I. General information

NPI: 1336231968
Provider Name (Legal Business Name): KEITH SEIDENBERG, MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 04/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 GODWIN AVE
MIDLAND PARK NJ
07432-1468
US

IV. Provider business mailing address

600 GODWIN AVE
MIDLAND PARK NJ
07432-1468
US

V. Phone/Fax

Practice location:
  • Phone: 201-447-9101
  • Fax: 201-447-9103
Mailing address:
  • Phone: 201-447-9101
  • Fax: 201-447-9103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number25MA05916500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: DR. KEITH B SEIDENBERG
Title or Position: PHYSICIAN
Credential: MD
Phone: 201-447-9101