Provider Demographics
NPI:1568425452
Name:SEO, MI LA (MD)
Entity Type:Individual
Prefix:
First Name:MI
Middle Name:LA
Last Name:SEO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602530
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2530
Mailing Address - Country:US
Mailing Address - Phone:910-642-1776
Mailing Address - Fax:910-642-9305
Practice Address - Street 1:500 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472
Practice Address - Country:US
Practice Address - Phone:910-642-1776
Practice Address - Fax:910-642-9305
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD27578207R00000X, 208M00000X
NC2009-01535207R00000X
KY39828207R00000X
NY286138207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1568425452Medicaid
SCNC1970Medicaid
KY000000387452OtherANTHEM BCBS
NCNCB816D238Medicare PIN
KY000000387452OtherANTHEM BCBS
NCNCB816CMedicare PIN
I47786Medicare UPIN
NC2075221DMedicare PIN
ORR181755Medicare PIN
KY0654818Medicare PIN
NCNCB816BMedicare PIN
NCNCB816EMedicare PIN
NC2075221BMedicare PIN
KY0614722Medicare PIN
SCNC1970Medicaid
NC2075221CMedicare PIN
NCNCB816DMedicare PIN
KY0758315Medicare PIN