Provider Demographics
NPI:1205809159
Name:SIEBERT, KARL J (MD)
Entity type:Individual
Prefix:
First Name:KARL
Middle Name:J
Last Name:SIEBERT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1000 E PARIS AVE SE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3680
Mailing Address - Country:US
Mailing Address - Phone:616-949-2001
Mailing Address - Fax:616-949-8620
Practice Address - Street 1:1000 E PARIS AVE SE
Practice Address - Street 2:SUITE 130
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3680
Practice Address - Country:US
Practice Address - Phone:616-949-2001
Practice Address - Fax:616-949-8620
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301073621174400000X, 207WX0009X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104094391Medicaid
MIG81418Medicare UPIN
MI104094391Medicaid