Provider Demographics
NPI:1174866354
Name:SIEBERT, DAVID MASON
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MASON
Last Name:SIEBERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 MONTLAKE BLVD NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98195
Mailing Address - Country:US
Mailing Address - Phone:206-598-3294
Mailing Address - Fax:
Practice Address - Street 1:3800 MONTLAKE BLVD NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-8021
Practice Address - Country:US
Practice Address - Phone:206-598-3294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-05
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60584255207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1174866354Medicaid