Provider Demographics
NPI:1720195910
Name:SEABURG, MARK A (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:SEABURG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2823 GRIFFIN AVE
Mailing Address - Street 2:
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-2322
Mailing Address - Country:US
Mailing Address - Phone:360-825-1614
Mailing Address - Fax:360-825-8034
Practice Address - Street 1:2823 GRIFFIN AVE
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-2322
Practice Address - Country:US
Practice Address - Phone:360-825-1614
Practice Address - Fax:360-825-8034
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001260152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2033207Medicaid
WA2033207Medicaid
WAG000104831Medicare ID - Type Unspecified
WA0646010001Medicare NSC