Provider Demographics
NPI:1790787927
Name:SEIDENBERG, JONATHAN ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:ALAN
Last Name:SEIDENBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2023 PULASKI HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:HAVRE DE GRACE
Mailing Address - State:MD
Mailing Address - Zip Code:21078
Mailing Address - Country:US
Mailing Address - Phone:410-939-6477
Mailing Address - Fax:410-939-6555
Practice Address - Street 1:2023 PULASKI HIGHWAY
Practice Address - Street 2:
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078
Practice Address - Country:US
Practice Address - Phone:410-939-6477
Practice Address - Fax:410-939-6555
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD38724207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
W2450003OtherFEDERAL BLUESHIELD
MD544711900Medicaid
MD42492601OtherCAREFIRST BLUESHILED
MD616L106DMedicare PIN
MDE21345Medicare UPIN
MD544711900Medicaid
W2450003OtherFEDERAL BLUESHIELD