Provider Demographics
NPI:1720514979
Name:SIEBERT, EMMELINE
Entity Type:Individual
Prefix:
First Name:EMMELINE
Middle Name:
Last Name:SIEBERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EMMELINE
Other - Middle Name:
Other - Last Name:CRUZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:50 STANIFORD ST STE 600
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2587
Mailing Address - Country:US
Mailing Address - Phone:617-367-4800
Mailing Address - Fax:617-723-7028
Practice Address - Street 1:50 STANIFORD ST STE 600
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2587
Practice Address - Country:US
Practice Address - Phone:617-367-4800
Practice Address - Fax:617-723-7028
Is Sole Proprietor?:No
Enumeration Date:2017-05-10
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5301152W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program