Provider Demographics
NPI:1336231968
Name:KEITH SEIDENBERG, MD LLC
Entity type:Organization
Organization Name:KEITH SEIDENBERG, MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:B
Authorized Official - Last Name:SEIDENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-447-9101
Mailing Address - Street 1:600 GODWIN AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07432-1468
Mailing Address - Country:US
Mailing Address - Phone:201-447-9101
Mailing Address - Fax:201-447-9103
Practice Address - Street 1:600 GODWIN AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND PARK
Practice Address - State:NJ
Practice Address - Zip Code:07432-1468
Practice Address - Country:US
Practice Address - Phone:201-447-9101
Practice Address - Fax:201-447-9103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05916500207W00000X
332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5790270001Medicare NSC