Provider Demographics
NPI:1932141850
Name:SIEBERT, MICHAEL JOSEPH (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:SIEBERT
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 1:1875 HAYNE ST UNIT 224
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29301-5108
Mailing Address - Country:US
Mailing Address - Phone:305-672-8513
Mailing Address - Fax:864-576-4748
Practice Address - Street 1:205 W BLACKSTOCK RD STE 150
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-3205
Practice Address - Country:US
Practice Address - Phone:864-574-8454
Practice Address - Fax:864-576-4748
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1547152W00000X
FL3400152WC0802X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Not Answered152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD15473Medicaid