Provider Demographics
NPI:1194385161
Name:SIEGEL, JORDAN R
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:R
Last Name:SIEGEL
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 1:10821 WILLOW RUN CT
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-2581
Mailing Address - Country:US
Mailing Address - Phone:202-486-3747
Mailing Address - Fax:
Practice Address - Street 1:423 E 23RD ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-5011
Practice Address - Country:US
Practice Address - Phone:305-575-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD167751223G0001X
FLDN239691223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223G0001XDental ProvidersDentistGeneral Practice