Provider Demographics
NPI:1477549475
Name:SIEDLECKI, ALAN
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:
Last Name:SIEDLECKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:779 GOLF DR
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:779 GOLF DR
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581
Practice Address - Country:US
Practice Address - Phone:516-791-0145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-25
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY216691207K00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI53425Medicare UPIN
NY5N9401Medicare PIN