Basic Information
| Provider Information | |||||||||
| NPI: | 1124065800 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SEIDENBERG PROTZKO EYE ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2023 PULASKI HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | HAVRE DE GRACE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210783719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109396477 | ||||||||
| FaxNumber: | 4109396555 | ||||||||
| Practice Location | |||||||||
| Address1: | 2023 PULASKI HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | HAVRE DE GRACE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210783719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109396477 | ||||||||
| FaxNumber: | 4109396555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 03/01/2010 | ||||||||
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| AuthorizedOfficialLastName: | SEIDENBERG | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
| AuthorizedOfficialMiddleName: | ALLAN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4109396477 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | D0038724 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 518901200 | 05 | MD | MEDICAID |