Healthcare Provider Details

I. General information

NPI: 1467622753
Provider Name (Legal Business Name): SELMA J. SHERIDAN MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2008
Last Update Date: 01/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 W 7TH ST
OSWEGO NY
13126-3676
US

IV. Provider business mailing address

209 W 7TH ST
OSWEGO NY
13126-3676
US

V. Phone/Fax

Practice location:
  • Phone: 315-343-9022
  • Fax:
Mailing address:
  • Phone: 315-343-9022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number132758
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number1121450001
License Number StateNY

VIII. Authorized Official

Name: DR. SELMA J. SHERIDAN
Title or Position: OWNER
Credential: MD
Phone: 315-343-9022