Provider Demographics
NPI:1073675690
Name:SIEGMUND, JASON (OD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:SIEGMUND
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 1:8077 VERONA DR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-8001
Mailing Address - Country:US
Mailing Address - Phone:843-626-6210
Mailing Address - Fax:843-692-3094
Practice Address - Street 1:540 SEABOARD ST
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577
Practice Address - Country:US
Practice Address - Phone:843-626-6210
Practice Address - Fax:843-692-3094
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC1389152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC41155OtherSPECTERA
SCD13894Medicaid