Provider Demographics
NPI:1295724243
Name:SIEBRECHT, MARK ALLEN (DPM)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:SIEBRECHT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 W LUCAS ST
Mailing Address - Street 2:
Mailing Address - City:MARENGO
Mailing Address - State:IA
Mailing Address - Zip Code:52301-1331
Mailing Address - Country:US
Mailing Address - Phone:319-741-6789
Mailing Address - Fax:319-741-6791
Practice Address - Street 1:255 W. LUCAS ST.
Practice Address - Street 2:
Practice Address - City:MARENGO
Practice Address - State:IA
Practice Address - Zip Code:52301
Practice Address - Country:US
Practice Address - Phone:319-741-6789
Practice Address - Fax:319-741-6791
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00701213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA35111OtherWELLMARK PROVIDER NUMBER
IA2221713Medicaid
IA2221713Medicaid
IA35111OtherWELLMARK PROVIDER NUMBER