Provider Demographics
NPI:1013164672
Name:SEABOLD, SUSAN ANDREA (OD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:ANDREA
Last Name:SEABOLD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2545 IL ROUTE 26 S
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-9370
Mailing Address - Country:US
Mailing Address - Phone:815-266-2037
Mailing Address - Fax:815-266-2038
Practice Address - Street 1:2545 IL ROUTE 26 S
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-9370
Practice Address - Country:US
Practice Address - Phone:815-266-2037
Practice Address - Fax:815-266-2038
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-25
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.010192152W00000X
TN2842152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist