Provider Demographics
NPI:1104998509
Name:SEYMOUR, GINA IRENE (OD)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:IRENE
Last Name:SEYMOUR
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14589 ASPEN CT
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-4462
Mailing Address - Country:US
Mailing Address - Phone:972-406-3057
Mailing Address - Fax:
Practice Address - Street 1:2301 N COLLINS ST STE 124
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76011-2662
Practice Address - Country:US
Practice Address - Phone:817-860-9050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5155TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU62254Medicare UPIN