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General NPI Number Information
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NPI Number | 1013164672
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Entity Type | Individual
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Provider Name | SUSAN ANDREA SEABOLD O.D.
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Gender | Female
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Dates
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Enumeration Date | 08/25/2008
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Last Update Date | 05/07/2009
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Provider Practice Location Address
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Address Line | 2545 IL ROUTE 26 S
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City | FREEPORT
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State | IL
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Zip | 61032-9370
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Country | US
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Telephone | 815-266-2037
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Fax | 815-266-2038
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Provider Business Mailing Address
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Address Line | 2545 IL ROUTE 26 S
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City | FREEPORT
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State | IL
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Zip | 61032-9370
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Country | US
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Telephone | 815-266-2037
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Fax | 815-266-2038
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 046.010192
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2842
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License Number State | TN
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