Provider Demographics
NPI:1366440661
Name:SIBOLD, SOPHIA A (DO)
Entity Type:Individual
Prefix:DR
First Name:SOPHIA
Middle Name:A
Last Name:SIBOLD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:SOPHIA
Other - Middle Name:A
Other - Last Name:SIMMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:200 HEALTH CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:WV
Mailing Address - Zip Code:24983-0000
Mailing Address - Country:US
Mailing Address - Phone:304-772-3064
Mailing Address - Fax:304-772-3296
Practice Address - Street 1:200 HEALTH CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:WV
Practice Address - Zip Code:24983-0000
Practice Address - Country:US
Practice Address - Phone:304-772-3064
Practice Address - Fax:304-772-3296
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2102207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV176557OtherANTHEM BC/BS-UNION
WVP00206497OtherRAILROAD MEDICARE
WV5611053OtherAETNA
VAVAA104451OtherGROUP PTAN
WV176558OtherPETERSTOWN
WV001714321OtherBC/BS
WV3810001719Medicaid
WV8130658OtherMAMSI
WV5611053OtherAETNA
WV511837Medicare Oscar/Certification
WVSI2025982Medicare PIN
WV8130658OtherMAMSI
VAVAA104451OtherGROUP PTAN