=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164476909
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN BARRY SIEBENLIST M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2006
-----------------------------------------------------
Last Update Date | 03/16/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1551 BISHOP ST SUITE 220
-----------------------------------------------------
City | SAN LUIS OBISPO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93401-4635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-541-0668
-----------------------------------------------------
Fax | 805-541-8213
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2285 CORPORATE CIR STE 200
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89074-7759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-360-2763
-----------------------------------------------------
Fax | 949-783-2880
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207NS0135X
-----------------------------------------------------
Taxonomy Name | Procedural Dermatology Physician
-----------------------------------------------------
License Number | A61826
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207ND0101X
-----------------------------------------------------
Taxonomy Name | MOHS-Micrographic Surgery Physician
-----------------------------------------------------
License Number | A61826
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------