Healthcare Provider Details

I. General information

NPI: 1720195910
Provider Name (Legal Business Name): MARK A SEABURG OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 06/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2823 GRIFFIN AVE
ENUMCLAW WA
98022-2322
US

IV. Provider business mailing address

2823 GRIFFIN AVE
ENUMCLAW WA
98022-2322
US

V. Phone/Fax

Practice location:
  • Phone: 360-825-1614
  • Fax: 360-825-8034
Mailing address:
  • Phone: 360-825-1614
  • Fax: 360-825-8034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD00001260
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2033207
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: