Healthcare Provider Details

I. General information

NPI: 1114059136
Provider Name (Legal Business Name): IRINEO MINA SIBAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3485 MIKE PADGETT HWY
AUGUSTA GA
30906-3815
US

IV. Provider business mailing address

3485 MIKE PADGETT HWY
AUGUSTA GA
30906-3815
US

V. Phone/Fax

Practice location:
  • Phone: 706-771-7843
  • Fax:
Mailing address:
  • Phone: 706-771-7843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number0018845
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number0018845
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: