Provider Demographics
NPI:1386667335
Name:SIEGFREID, SUSAN LYNN (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYNN
Last Name:SIEGFREID
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 1:2637 N. WASHINGTON BLVD. #132
Mailing Address - Street 2:
Mailing Address - City:NORTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84414-0000
Mailing Address - Country:US
Mailing Address - Phone:801-928-4798
Mailing Address - Fax:
Practice Address - Street 1:1279 W 3000 S
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:UT
Practice Address - Zip Code:84302-6712
Practice Address - Country:US
Practice Address - Phone:801-928-4798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20001713662084P0800X
NC98-017712084P0800X
NM97-1442084P0800X
UT6517478-12052084P0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891178HMedicaid
NC2266972Medicare ID - Type UnspecifiedUSED 1998-2000 AS FELLOW