Provider Demographics
NPI:1336805183
Name:SEO, ANTHONY JAE
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:JAE
Last Name:SEO
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 1:10810 SYMINGTON CIR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-1282
Mailing Address - Country:US
Mailing Address - Phone:502-445-0377
Mailing Address - Fax:
Practice Address - Street 1:1475 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40210-1767
Practice Address - Country:US
Practice Address - Phone:502-776-1840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-15
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY022465183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist