Healthcare Provider Details

I. General information

NPI: 1295724243
Provider Name (Legal Business Name): MARK ALLEN SIEBRECHT D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 09/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 W. LUCAS ST.
MARENGO IA
52301
US

IV. Provider business mailing address

255 W LUCAS ST
MARENGO IA
52301-1331
US

V. Phone/Fax

Practice location:
  • Phone: 319-741-6789
  • Fax: 319-741-6791
Mailing address:
  • Phone: 319-741-6789
  • Fax: 319-741-6791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number00701
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: