Provider Demographics
NPI:1255392122
Name:SYBESMA, DAVID SCOTT (OD PC)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:SCOTT
Last Name:SYBESMA
Suffix:
Gender:M
Credentials:OD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 43RD STREET
Mailing Address - Street 2:
Mailing Address - City:MAQUOKETA
Mailing Address - State:IA
Mailing Address - Zip Code:52060
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
Practice Address - Country:US
Practice Address - Phone:563-652-2795
Practice Address - Fax:563-652-5210
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2014-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1996152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
410024770OtherRAILROAD MEDICARE
IA1106880Medicaid
5380340001OtherCIGNA DME REGION D
IA14965OtherWELLMARK BCBS
IA1106880Medicaid