Provider Demographics
NPI:1851622393
Name:SIEBENLIST, BUDDY ROGER (MD)
Entity Type:Individual
Prefix:DR
First Name:BUDDY
Middle Name:ROGER
Last Name:SIEBENLIST
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:PO BOX 1857
Mailing Address - Street 2:
Mailing Address - City:WASKOM
Mailing Address - State:TX
Mailing Address - Zip Code:75692-1857
Mailing Address - Country:US
Mailing Address - Phone:903-935-2800
Mailing Address - Fax:
Practice Address - Street 1:757 BELLVIEW RD
Practice Address - Street 2:
Practice Address - City:WASKOM
Practice Address - State:TX
Practice Address - Zip Code:75692-3425
Practice Address - Country:US
Practice Address - Phone:903-935-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-22
Last Update Date:2011-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH40762085R0202X
LA0102602085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB61743Medicare UPIN