Provider Demographics
NPI:1619184504
Name:DR. TIM R. SEIFERT, OPTOMETRIST, S.C.
Entity Type:Organization
Organization Name:DR. TIM R. SEIFERT, OPTOMETRIST, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF S.C.
Authorized Official - Prefix:DR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:R
Authorized Official - Last Name:SEIFERT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:262-367-6610
Mailing Address - Street 1:211 COTTONWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53029-2016
Mailing Address - Country:US
Mailing Address - Phone:262-367-6610
Mailing Address - Fax:
Practice Address - Street 1:211 COTTONWOOD AVE
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:WI
Practice Address - Zip Code:53029-2016
Practice Address - Country:US
Practice Address - Phone:262-367-6610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1488152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38558800Medicaid
WIP63298Medicare UPIN