Basic Information
| Provider Information | |||||||||
| NPI: | 1164476909 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIEBENLIST | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | BARRY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2285 CORPORATE CIR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890747759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023602763 | ||||||||
| FaxNumber: | 9497832880 | ||||||||
| Practice Location | |||||||||
| Address1: | 1551 BISHOP ST | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934014635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055410668 | ||||||||
| FaxNumber: | 8055418213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 03/16/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207NS0135X | A61826 | CA | Y | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology | 207ND0101X | A61826 | CA | N | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery |
ID Information
| ID | Type | State | Issuer | Description | P00146047 | 01 | CA | RAILROAD MEDICARE | OTHER |