Provider Demographics
NPI:1265452908
Name:SIEGEL, JERRY (OD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
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 1:1919 VAN BUREN ST
Mailing Address - Street 2:#307
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-7810
Mailing Address - Country:US
Mailing Address - Phone:954-838-0700
Mailing Address - Fax:
Practice Address - Street 1:13550 W SUNRISE BLVD
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-3902
Practice Address - Country:US
Practice Address - Phone:954-838-0700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC695152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL19216Medicare ID - Type Unspecified
FLT83910Medicare UPIN