Provider Demographics
NPI:1558346973
Name:SEALOCK, RON (OD)
Entity Type:Individual
Prefix:
First Name:RON
Middle Name:
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 1:1623 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-1315
Mailing Address - Country:US
Mailing Address - Phone:334-793-9607
Mailing Address - Fax:334-677-1124
Practice Address - Street 1:1623 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-1315
Practice Address - Country:US
Practice Address - Phone:334-793-9607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-08
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS371TA081152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000059644Medicaid
AL000059644Medicare ID - Type Unspecified
AL1063686863Medicare NSC
AL3883990001Medicare NSC