Basic Information
| Provider Information | |||||||||
| NPI: | 1821001116 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SEIDEL | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | HESTON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1720 SOUTH BECKHAM AVE | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035955101 | ||||||||
| FaxNumber: | 9035972314 | ||||||||
| Practice Location | |||||||||
| Address1: | 1720 SOUTH BECKHAM AVE | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035955101 | ||||||||
| FaxNumber: | 9035972314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 04/21/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | J4508 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 75-2616977-008 | 01 | TX | TRICARE | OTHER | 100011163 | 01 | TX | RAIL ROAD MEDICARE | OTHER | 75-2616977-054 | 01 | TX | TRICARE | OTHER | 104033903 | 05 | TX | MEDICAID | 8GC765 | 01 | TX | BCBS | OTHER | 75-2616977-125 | 01 | TX | TRICARE | OTHER | 104033907 | 05 | TX | MEDICAID |