Provider Demographics
NPI:1629097035
Name:COBLE, SELLAS PECOS (DO)
Entity Type:Individual
Prefix:
First Name:SELLAS
Middle Name:PECOS
Last Name:COBLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 BLUES LAKE PKWY
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-8022
Mailing Address - Country:US
Mailing Address - Phone:573-364-8822
Mailing Address - Fax:573-202-2404
Practice Address - Street 1:600 BLUES LAKE PKWY
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-8022
Practice Address - Country:US
Practice Address - Phone:573-364-8822
Practice Address - Fax:573-202-2404
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO116667207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00063568OtherRAILROAD MEDICARE
MO457663OtherHEALTHLINK
MO143206OtherBLUE CROSS BLUE SHIELD OF
MO110236209OtherRAILROAD MEDICARE
MO245304902Medicaid