Provider Demographics
NPI:1588074140
Name:SEIBOLT, LUCAS (MD)
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:
Last Name:SEIBOLT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:LUCAS
Other - Middle Name:
Other - Last Name:SEIBOLT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2409 N PATTERSON ST STE 310
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2512
Mailing Address - Country:US
Mailing Address - Phone:229-433-8160
Mailing Address - Fax:229-244-2707
Practice Address - Street 1:2409 N PATTERSON ST STE 310
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2512
Practice Address - Country:US
Practice Address - Phone:229-433-8160
Practice Address - Fax:229-244-2707
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-05
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR74418207R00000X
AZ54189207R00000X
IN01083408A207RC0000X
AZ252293207UN0901X, 2471C3401X
GA88599207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
No2471C3401XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistComputed Tomography