Provider Demographics
NPI:1891881512
Name:SEYLLER, WENDY (OD)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:SEYLLER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1037 GRIFFIN AVE
Mailing Address - Street 2:
Mailing Address - City:MAHTOMEDI
Mailing Address - State:MN
Mailing Address - Zip Code:55115-1509
Mailing Address - Country:US
Mailing Address - Phone:651-493-2677
Mailing Address - Fax:
Practice Address - Street 1:13481 60TH ST N SUITE 200
Practice Address - Street 2:ST CROIX VISION CENTER
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082
Practice Address - Country:US
Practice Address - Phone:651-439-6400
Practice Address - Fax:651-439-6405
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2105152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN11960OtherEYE MED / COLE VISION
MN3C312SEOtherBLUE CROSS BLUE SHIELD
MN670360700Medicaid
MNU40552Medicare UPIN
MN670360700Medicaid