Provider Demographics
NPI:1316900566
Name:SEO, JWA-IL JAMES (MD)
Entity type:Individual
Prefix:
First Name:JWA-IL
Middle Name:JAMES
Last Name:SEO
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 1:4560 OBERLIN AVE
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-3195
Mailing Address - Country:US
Mailing Address - Phone:440-282-7034
Mailing Address - Fax:440-282-5569
Practice Address - Street 1:4560 OBERLIN AVE
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-3195
Practice Address - Country:US
Practice Address - Phone:440-282-7034
Practice Address - Fax:440-282-5569
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35034281208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0301307Medicaid
OHSE0729701Medicare PIN
OHF47211Medicare UPIN