Provider Demographics
NPI:1417482803
Name:SIEGEL, ELISA MICHELLE
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:MICHELLE
Last Name:SIEGEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 RICHARD AVE
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-2314
Mailing Address - Country:US
Mailing Address - Phone:516-208-3802
Mailing Address - Fax:
Practice Address - Street 1:1640 RICHARD AVE
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-2314
Practice Address - Country:US
Practice Address - Phone:516-208-3802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-24
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1787964174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist