Provider Demographics
NPI:1043742695
Name:SPIEGEL, SAMUEL JUSTIN
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JUSTIN
Last Name:SPIEGEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-301-8707
Mailing Address - Fax:650-498-6205
Practice Address - Street 1:625 S FAIR OAKS AVE STE 280
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2670
Practice Address - Country:US
Practice Address - Phone:626-817-4747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA159963207WX0109X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0109XAllopathic & Osteopathic PhysiciansOphthalmologyNeuro-ophthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program