Provider Demographics
NPI:1699705145
Name:SEAQUIST, JACK L (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:L
Last Name:SEAQUIST
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:PO BOX 26726
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78755-0726
Mailing Address - Country:US
Mailing Address - Phone:512-407-8686
Mailing Address - Fax:512-421-4489
Practice Address - Street 1:1301 W. 38TH ST. #102
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1010
Practice Address - Country:US
Practice Address - Phone:512-454-4561
Practice Address - Fax:512-467-2906
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD9654207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX117193604Medicaid
TX817420OtherSCOTT & WHITE
TX817420OtherBCBS
TX094771502Medicaid
TX4048662OtherAETNA TRS
TXP00847935Medicare PIN
TX117193604Medicaid
TXTXB104415Medicare PIN
TX817420OtherSCOTT & WHITE