Provider Demographics
NPI:1114903143
Name:SIEBEN, CANDICE M (MD)
Entity Type:Individual
Prefix:DR
First Name:CANDICE
Middle Name:M
Last Name:SIEBEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:910-579-8363
Mailing Address - Fax:910-579-8306
Practice Address - Street 1:75 EMERSON BAY RD
Practice Address - Street 2:SUITE 102
Practice Address - City:CAROLINA SHORES
Practice Address - State:NC
Practice Address - Zip Code:28467-2498
Practice Address - Country:US
Practice Address - Phone:910-579-8363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35075365207Q00000X
NC2016-00432207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2194325Medicaid
OH2194325Medicaid
OHH21795Medicare UPIN
OH4029835Medicare PIN