Provider Demographics
NPI:1306821525
Name:SIEGEL, JON L (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:L
Last Name:SIEGEL
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:PO BOX 1746
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1746
Mailing Address - Country:US
Mailing Address - Phone:877-383-4442
Mailing Address - Fax:678-553-7793
Practice Address - Street 1:1000 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-7694
Practice Address - Country:US
Practice Address - Phone:678-312-4440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0342432085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000604106CMedicaid
GAP00990794OtherRR MEDICARE
GA000604106CMedicaid
GA511G700002Medicare PIN
GAP00990794OtherRR MEDICARE
GA511I300061Medicare PIN
GA30BDFRHMedicare PIN