Provider Demographics
NPI:1295915494
Name:SEYBOLT, STEPHAN D
Entity type:Individual
Prefix:MR
First Name:STEPHAN
Middle Name:D
Last Name:SEYBOLT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 S CASCADE DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14141-9275
Mailing Address - Country:US
Mailing Address - Phone:716-592-7031
Mailing Address - Fax:
Practice Address - Street 1:184 S CASCADE DR
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:14141-9275
Practice Address - Country:US
Practice Address - Phone:716-592-7031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-06
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044707183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist