Provider Demographics
NPI:1154618528
Name:SEIBERT, JENNIFER V (OD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:V
Last Name:SEIBERT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:MARIA
Other - Last Name:VIRAG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3490 DAMASCUS CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29020-9188
Mailing Address - Country:US
Mailing Address - Phone:864-650-4515
Mailing Address - Fax:
Practice Address - Street 1:1057 BROAD ST
Practice Address - Street 2:#48
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-2567
Practice Address - Country:US
Practice Address - Phone:803-775-8951
Practice Address - Fax:803-775-8955
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011020051152W00000X, 152WP0200X, 152WV0400X
SC1717152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1154618528Medicaid
MO074730018Medicare PIN
MO1154618528Medicaid
MO067820015Medicare PIN