Provider Demographics
NPI:1164476909
Name:SIEBENLIST, JOHN BARRY (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BARRY
Last Name:SIEBENLIST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2285 CORPORATE CIR
Mailing Address - Street 2:STE 200
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-7759
Mailing Address - Country:US
Mailing Address - Phone:702-360-2763
Mailing Address - Fax:949-783-2880
Practice Address - Street 1:1551 BISHOP ST
Practice Address - Street 2:SUITE 220
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4635
Practice Address - Country:US
Practice Address - Phone:805-541-0668
Practice Address - Fax:805-541-8213
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61826207NS0135X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00146047OtherRAILROAD MEDICARE
CAAQ656RMedicare PIN
CAAQ656TMedicare PIN
CA00A618260Medicare PIN
CAAQ656WMedicare PIN
CAP00146047OtherRAILROAD MEDICARE
CAAQ656SMedicare PIN
CAAQ656XMedicare PIN
CAAQ656YMedicare PIN
CAH14183Medicare UPIN
CAAQ656UMedicare PIN
CAAQ656VMedicare PIN
CAAQ656ZMedicare PIN
CAWA61826AMedicare PIN