Provider Demographics
NPI:1437508587
Name:SEABURG, SCOTT MARK (OD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:MARK
Last Name:SEABURG
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 1:645 N MICHIGAN AVE
Mailing Address - Street 2:STE. 210
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2826
Mailing Address - Country:US
Mailing Address - Phone:312-787-2020
Mailing Address - Fax:
Practice Address - Street 1:645 N MICHIGAN AVE
Practice Address - Street 2:STE. 210
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2826
Practice Address - Country:US
Practice Address - Phone:312-787-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-09
Last Update Date:2016-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011016152W00000X
WAOD60643254152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist