Provider Demographics
NPI:1104184951
Name:SEALES, THOMAS JACOB (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JACOB
Last Name:SEALES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 740923
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-0923
Mailing Address - Country:US
Mailing Address - Phone:850-863-2153
Mailing Address - Fax:
Practice Address - Street 1:1034 MAR WALT DR UNIT 100
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6637
Practice Address - Country:US
Practice Address - Phone:850-863-2153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-30
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FL131396207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL02171200Medicaid
FLON9E7OtherBCBS
FL14092927OtherCAQH