Provider Demographics
NPI:1962521757
Name:SEFFINGER, MICKEY AVRAM (DO)
Entity type:Individual
Prefix:
First Name:MICKEY
Middle Name:AVRAM
Last Name:SEFFINGER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:PROF
Other - First Name:MICHAEL
Other - Middle Name:A
Other - Last Name:SEFFINGER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:795 E SECOND STREET
Mailing Address - Street 2:SUITE 5
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-2007
Mailing Address - Country:US
Mailing Address - Phone:909-865-2565
Mailing Address - Fax:909-865-2955
Practice Address - Street 1:795 E. SECOND ST.
Practice Address - Street 2:SUITE 5
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-2007
Practice Address - Country:US
Practice Address - Phone:909-865-2565
Practice Address - Fax:909-865-2955
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5745204D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABZ219ZOtherMEDICARE PTAN SO CA
CABZ219XOtherMEDICARE PTAN NO CA