Provider Demographics
NPI:1679518245
Name:JACK D. SEIDEL, M.D., P.A.
Entity Type:Organization
Organization Name:JACK D. SEIDEL, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:SEIDEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-243-5437
Mailing Address - Street 1:4100 ALPHA RD STE 650
Mailing Address - Street 2:
Mailing Address - City:FARMERS BRANCH
Mailing Address - State:TX
Mailing Address - Zip Code:75244-4381
Mailing Address - Country:US
Mailing Address - Phone:972-243-5437
Mailing Address - Fax:
Practice Address - Street 1:4100 ALPHA RD STE 650
Practice Address - Street 2:
Practice Address - City:FARMERS BRANCH
Practice Address - State:TX
Practice Address - Zip Code:75244-4381
Practice Address - Country:US
Practice Address - Phone:972-243-5437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH3940208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP000K94L2Medicaid