Healthcare Provider Details

I. General information

NPI: 1548268782
Provider Name (Legal Business Name): SEI C OH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 02/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 S ARCHIE ST
VIDOR TX
77662-4868
US

IV. Provider business mailing address

515 S ARCHIE ST
VIDOR TX
77662-4868
US

V. Phone/Fax

Practice location:
  • Phone: 409-769-2295
  • Fax: 409-769-3373
Mailing address:
  • Phone: 409-769-2295
  • Fax: 409-769-3373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberF2379
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: