Healthcare Provider Details

I. General information

NPI: 1588074140
Provider Name (Legal Business Name): LUCAS SEIBOLT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: LUCAS SEIBOLT M.D.

II. Dates (important events)

Enumeration Date: 05/05/2014
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2409 N PATTERSON ST STE 310
VALDOSTA GA
31602-2512
US

IV. Provider business mailing address

2409 N PATTERSON ST STE 310
VALDOSTA GA
31602-2512
US

V. Phone/Fax

Practice location:
  • Phone: 229-433-8160
  • Fax: 229-244-2707
Mailing address:
  • Phone: 229-433-8160
  • Fax: 229-244-2707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberR74418
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number54189
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number01083408A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number252293
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code2471C3401X
TaxonomyComputed Tomography Radiologic Technologist
License Number252293
License Number StateAZ
# 6
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number88599
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: