Provider Demographics
NPI:1033446919
Name:SIEGEL, EDWIN (OD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:SIEGEL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6407 RECREATION LANE
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22041
Mailing Address - Country:US
Mailing Address - Phone:703-920-2020
Mailing Address - Fax:703-920-3852
Practice Address - Street 1:PENTAGON CONCOURSE ROOM 2C113
Practice Address - Street 2:PENTAGON VISION CENTER
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20301
Practice Address - Country:US
Practice Address - Phone:703-920-2020
Practice Address - Fax:703-920-3852
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-12
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000674152W00000X
DCOP406152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist