Provider Demographics
NPI:1679770036
Name:SEYMORE, DOMINIC SHAY (MD)
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:SHAY
Last Name:SEYMORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 N PARK TRL
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-6500
Mailing Address - Country:US
Mailing Address - Phone:770-506-1800
Mailing Address - Fax:770-506-4686
Practice Address - Street 1:165 N PARK TRL
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-6500
Practice Address - Country:US
Practice Address - Phone:770-506-1800
Practice Address - Fax:770-506-4686
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA063530208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA936797692EMedicaid
GA936797692CMedicaid
GA936797692AMedicaid
GA936797692BMedicaid
GA936797692GMedicaid
GA936797692DMedicaid