Basic Information
Provider Information | |||||||||
NPI: | 1720145766 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SEIDENBERG PROTZKO EYE ASSOCIATES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2023 PULASKI HIGHWAY | ||||||||
Address2: |   | ||||||||
City: | HAVRE DEGRACE | ||||||||
State: | MD | ||||||||
PostalCode: | 21078 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4109396477 | ||||||||
FaxNumber: | 4109396555 | ||||||||
Practice Location | |||||||||
Address1: | 520 UPPER CHESAPEAKE DR | ||||||||
Address2: | SUITE 401 | ||||||||
City: | BEL AIR | ||||||||
State: | MD | ||||||||
PostalCode: | 210144339 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4436434505 | ||||||||
FaxNumber: | 4436434510 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/02/2007 | ||||||||
LastUpdateDate: | 03/19/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | REED | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | OPTICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 4436434505 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | O.D | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | TA1239 | MD | Y |   | Suppliers | Eyewear Supplier (Equipment, not the service) |   |
ID Information
ID | Type | State | Issuer | Description | KF61 | 01 | MD | CAREFIRST BLUESHIELD | OTHER | W245 | 01 | MD | CAREFIRST NCA | OTHER |