Provider Demographics
NPI:1427018266
Name:SEALOCK, DONALD H (OD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:H
Last Name:SEALOCK
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 1:4455 HIGHWAY 169 N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55442-2897
Mailing Address - Country:US
Mailing Address - Phone:763-559-7358
Mailing Address - Fax:763-559-2167
Practice Address - Street 1:4455 HIGHWAY 169 N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55442-2897
Practice Address - Country:US
Practice Address - Phone:763-559-7358
Practice Address - Fax:763-559-2167
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2103152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN408723200Medicaid
MN410000030Medicare ID - Type Unspecified
MN408723200Medicaid