Provider Demographics
NPI:1114062999
Name:WEST, SEAN (OD)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:WEST
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06615-7406
Mailing Address - Country:US
Mailing Address - Phone:203-377-2020
Mailing Address - Fax:203-381-9936
Practice Address - Street 1:775 MAIN ST
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06615-7406
Practice Address - Country:US
Practice Address - Phone:203-377-2020
Practice Address - Fax:203-381-9936
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11978T152W00000X
CT002824152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0119780Medicaid
CAMW1128708OtherDEA
CASD0119781Medicare PIN
CASD0119784Medicare PIN
CAMW1128708OtherDEA
CASD0119783Medicare PIN
CASD0119782Medicare PIN