Provider Demographics
NPI:1437140514
Name:SIEGEL, GLENN MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:MICHAEL
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 1:761 MAIN AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-1080
Mailing Address - Country:US
Mailing Address - Phone:203-838-4000
Mailing Address - Fax:203-845-9535
Practice Address - Street 1:761 MAIN AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-1080
Practice Address - Country:US
Practice Address - Phone:203-838-4000
Practice Address - Fax:203-845-9535
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT044239207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004187466Medicaid
CT004187466Medicaid