Provider Demographics
NPI:1508197062
Name:MITCHELL S. SEIDMAN, PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:MITCHELL S. SEIDMAN, PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:SEIDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:718-332-2020
Mailing Address - Street 1:2989 OCEAN PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-8386
Mailing Address - Country:US
Mailing Address - Phone:718-332-2020
Mailing Address - Fax:718-332-3248
Practice Address - Street 1:2989 OCEAN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-8386
Practice Address - Country:US
Practice Address - Phone:718-332-2020
Practice Address - Fax:718-332-3248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-22
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY135268207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00434753Medicaid
NYA100023556OtherMEDICARE PTAN
NY135268OtherLICENSE