Healthcare Provider Details

I. General information

NPI: 1104359470
Provider Name (Legal Business Name): LEMUEL YIA SIBULO JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2017
Last Update Date: 06/13/2023
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1402 S GRAND BLVD M260
SAINT LOUIS MO
63104-1004
US

IV. Provider business mailing address

11361 CORSICA MIST AVE
LAS VEGAS NV
89135-1338
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-9853
  • Fax:
Mailing address:
  • Phone: 503-330-0389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2021047392
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: