Provider Demographics
NPI:1912991233
Name:SEYDEL, JERRY LYNN (MD)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:LYNN
Last Name:SEYDEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93301-1713
Mailing Address - Country:US
Mailing Address - Phone:661-861-9000
Mailing Address - Fax:661-861-9132
Practice Address - Street 1:2801 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-1713
Practice Address - Country:US
Practice Address - Phone:661-861-9000
Practice Address - Fax:661-861-9132
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA35491208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A354910Medicaid
CA00A354910Medicare ID - Type Unspecified
CA00A354910Medicaid