Provider Demographics
NPI:1376656561
Name:SIEGAL, LORI (MD)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:SIEGAL
Suffix:
Gender:F
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:P.O. BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:6410 NE HALSEY STREET
Practice Address - Street 2:SUITE 300
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-4742
Practice Address - Country:US
Practice Address - Phone:503-215-2669
Practice Address - Fax:503-215-8465
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21229207R00000X
WAMD00045814207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORE84194Medicare UPIN