Provider Demographics
NPI:1063686863
Name:DR RONALD SEALOCK
Entity type:Organization
Organization Name:DR RONALD SEALOCK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:H
Authorized Official - Last Name:SEALOCK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:334-793-9607
Mailing Address - Street 1:1623 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-1315
Mailing Address - Country:US
Mailing Address - Phone:334-793-9607
Mailing Address - Fax:
Practice Address - Street 1:1623 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-1315
Practice Address - Country:US
Practice Address - Phone:334-793-9607
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS371TA081332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000059644Medicaid
AL000059644Medicaid
AL3883990001Medicare NSC