Provider Demographics
NPI:1376570168
Name:SIEGEL, STEPHEN J (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:J
Last Name:SIEGEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:28 CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3654
Mailing Address - Country:US
Mailing Address - Phone:860-358-4820
Mailing Address - Fax:860-358-8661
Practice Address - Street 1:80 SHUNPIKE RD
Practice Address - Street 2:SUITE 301
Practice Address - City:CROMWELL
Practice Address - State:CT
Practice Address - Zip Code:06416-4401
Practice Address - Country:US
Practice Address - Phone:860-632-5570
Practice Address - Fax:860-358-8650
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2017-04-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CT039774207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1397745Medicaid
CT1397745Medicaid
CTG70903Medicare UPIN