Provider Demographics
NPI:1114908233
Name:SIEGMAN, IRA L (MD)
Entity Type:Individual
Prefix:DR
First Name:IRA
Middle Name:L
Last Name:SIEGMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:278 S MOON AVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5711
Mailing Address - Country:US
Mailing Address - Phone:813-661-7704
Mailing Address - Fax:813-662-2134
Practice Address - Street 1:278 S MOON AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5711
Practice Address - Country:US
Practice Address - Phone:813-661-7704
Practice Address - Fax:813-662-2134
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0062934174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLW13312Medicare UPIN
FL26915ZMedicare ID - Type UnspecifiedMEDICARE NUMBER