Provider Demographics
NPI:1114214731
Name:SEIBOLD, SPENCER GARRETT (DO)
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:GARRETT
Last Name:SEIBOLD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83211-1362
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:502 TYHEE AVE
Practice Address - Street 2:
Practice Address - City:AMERICAN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83211-1224
Practice Address - Country:US
Practice Address - Phone:208-226-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-03
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-0803207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine