Provider Demographics
NPI:1215037908
Name:SEIDLITZ, TIMOTHY HOWARD (OD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:HOWARD
Last Name:SEIDLITZ
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:PO BOX 407
Mailing Address - Street 2:
Mailing Address - City:DUNSMUIR
Mailing Address - State:CA
Mailing Address - Zip Code:96025-0407
Mailing Address - Country:US
Mailing Address - Phone:530-235-2190
Mailing Address - Fax:530-235-2734
Practice Address - Street 1:4305 STAGECOACH RD
Practice Address - Street 2:
Practice Address - City:DUNSMUIR
Practice Address - State:CA
Practice Address - Zip Code:96025-1812
Practice Address - Country:US
Practice Address - Phone:530-235-2190
Practice Address - Fax:530-235-2734
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA7762T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0077620Medicaid
CAT10596Medicare UPIN
CA410001920Medicare ID - Type UnspecifiedRAILROAD MEDICARE
CASD0077620Medicare ID - Type UnspecifiedGENERAL ASSIGNED
CA0735600001Medicare NSC
CABJ317ZMedicare PIN