Provider Demographics
NPI:1376544833
Name:SIETSTRA, PHILIP G (OD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:G
Last Name:SIETSTRA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5116 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-2677
Mailing Address - Country:US
Mailing Address - Phone:605-338-7104
Mailing Address - Fax:605-575-3880
Practice Address - Street 1:5116 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-2677
Practice Address - Country:US
Practice Address - Phone:605-338-7104
Practice Address - Fax:605-575-3880
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDT143152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
410038933OtherRR MEDICARE
SD9201122Medicaid
57D35SIOtherBCBS OF MN
T66674Medicare UPIN
SD9201122Medicaid
SD5797Medicare PIN