Provider Demographics
NPI:1497785620
Name:DON SEALOCK, O.D., P.A.
Entity Type:Organization
Organization Name:DON SEALOCK, O.D., P.A.
Other - Org Name:FOUR SEASONS EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:H
Authorized Official - Last Name:SEALOCK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:763-559-7358
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2103152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN496562100Medicaid
MN0767130008Medicare NSC
MN496562100Medicaid
MN0767130006Medicare NSC
MN0767130001Medicare NSC