Provider Demographics
NPI:1780647057
Name:SIEBERT, DAVID CONRAD (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:CONRAD
Last Name:SIEBERT
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 1:1200 RIVERPLACE BLVD
Mailing Address - Street 2:620
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-9046
Mailing Address - Country:US
Mailing Address - Phone:904-396-6620
Mailing Address - Fax:904-396-6528
Practice Address - Street 1:1200 RIVERPLACE BLVD
Practice Address - Street 2:620
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-9046
Practice Address - Country:US
Practice Address - Phone:904-396-6620
Practice Address - Fax:904-396-6528
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88389207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269161200Medicaid
FL269161200Medicaid
H80417Medicare UPIN