Provider Demographics
NPI:1528180338
Name:SEASHOLTZ, IRA JOHN (DO)
Entity Type:Individual
Prefix:DR
First Name:IRA
Middle Name:JOHN
Last Name:SEASHOLTZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 NW CRANE AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:FL
Mailing Address - Zip Code:32340-1400
Mailing Address - Country:US
Mailing Address - Phone:580-973-2271
Mailing Address - Fax:850-973-2818
Practice Address - Street 1:224 NW CRANE AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:FL
Practice Address - Zip Code:32340-1400
Practice Address - Country:US
Practice Address - Phone:580-973-2271
Practice Address - Fax:850-973-2818
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS35792085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFLOS0003579OtherLICENSE
FL055322100Medicaid
FL81986CMedicare ID - Type Unspecified
FLFLOS0003579OtherLICENSE