Healthcare Provider Details

I. General information

NPI: 1851622393
Provider Name (Legal Business Name): BUDDY ROGER SIEBENLIST M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2010
Last Update Date: 10/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

757 BELLVIEW RD
WASKOM TX
75692-3425
US

IV. Provider business mailing address

PO BOX 1857
WASKOM TX
75692-1857
US

V. Phone/Fax

Practice location:
  • Phone: 903-935-2800
  • Fax:
Mailing address:
  • Phone: 903-935-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberH4076
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number010260
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: