Provider Demographics
NPI:1235309246
Name:SEBASTIAN, JEREMY S (MD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:S
Last Name:SEBASTIAN
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:512-406-6216
Practice Address - Street 1:3816 S 1ST ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-7048
Practice Address - Country:US
Practice Address - Phone:512-443-1311
Practice Address - Fax:512-406-6266
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM8983207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX199215804Medicaid
TX199215801Medicaid
TX8BL260OtherBCBS
TX199215805Medicaid
TX199215803Medicaid
TX8L2376Medicare PIN
TX199215805Medicaid
TX199215801Medicaid
TXP01321686Medicare PIN
TX199215803Medicaid