Provider Demographics
NPI:1447474630
Name:DAVID S SYBESMA, OD, PC
Entity type:Organization
Organization Name:DAVID S SYBESMA, OD, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:SYBESMA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:563-652-2795
Mailing Address - Street 1:1408 43RD STREET
Mailing Address - Street 2:
Mailing Address - City:MAQUOKETA
Mailing Address - State:IA
Mailing Address - Zip Code:52060-3056
Mailing Address - Country:US
Mailing Address - Phone:563-652-2795
Mailing Address - Fax:563-652-5210
Practice Address - Street 1:1408 43RD STREET
Practice Address - Street 2:
Practice Address - City:MAQUOKETA
Practice Address - State:IA
Practice Address - Zip Code:52060-3056
Practice Address - Country:US
Practice Address - Phone:563-652-2795
Practice Address - Fax:563-652-5210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1996152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA14965OtherBCBS OF IOWA
IA1106880Medicaid
IA1255392122OtherNPI
IAU47298Medicare UPIN
IA5380340001Medicare NSC
IAI11999Medicare ID - Type Unspecified