Provider Demographics
NPI:1982670212
Name:SIEBENALER, JACK II (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:SIEBENALER
Suffix:II
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 1:3232 NAVARRE AVE
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:OH
Mailing Address - Zip Code:43616-3312
Mailing Address - Country:US
Mailing Address - Phone:419-691-0636
Mailing Address - Fax:419-693-1412
Practice Address - Street 1:3232 NAVARRE AVE
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-3312
Practice Address - Country:US
Practice Address - Phone:419-691-0636
Practice Address - Fax:419-693-1412
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35053850207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0636539Medicaid
OHD32448Medicare UPIN
OHSI0604182Medicare ID - Type Unspecified
OH0636539Medicaid