Provider Demographics
NPI:1760423271
Name:SEIDE-JUSTIN, MARIE LAURETTA (OD)
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:LAURETTA
Last Name:SEIDE-JUSTIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6601 OLD WINTER GARDEN RD
Mailing Address - Street 2:SNIT 104
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-1370
Mailing Address - Country:US
Mailing Address - Phone:407-292-9812
Mailing Address - Fax:407-292-9813
Practice Address - Street 1:6601 OLD WINTER GARDEN RD
Practice Address - Street 2:UNIT 104
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-1370
Practice Address - Country:US
Practice Address - Phone:407-292-9812
Practice Address - Fax:407-292-9813
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC003955152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL621147000Medicaid
FL621147000Medicaid
FLAB735YMedicare PIN