Provider Demographics
NPI:1568542611
Name:SEYBOTH, CLARK LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:CLARK
Middle Name:LEE
Last Name:SEYBOTH
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:920 PROVIDENCE RD
Mailing Address - Street 2:STE 100
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-2976
Mailing Address - Country:US
Mailing Address - Phone:410-486-1010
Mailing Address - Fax:443-895-4822
Practice Address - Street 1:825 DULANEY VALLEY RD
Practice Address - Street 2:SUITE 302
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-1010
Practice Address - Country:US
Practice Address - Phone:410-825-5343
Practice Address - Fax:410-825-6419
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2020-09-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MDTAO927152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U02928Medicare UPIN