Provider Demographics
NPI:1477560902
Name:SIEGEL, FRED HARRIS (MD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:HARRIS
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 1:700 BATTLEFIELD BLVD N STE A
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-4952
Mailing Address - Country:US
Mailing Address - Phone:757-547-2115
Mailing Address - Fax:757-547-8644
Practice Address - Street 1:700 BATTLEFIELD BLVD N STE A
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4952
Practice Address - Country:US
Practice Address - Phone:757-547-2115
Practice Address - Fax:757-547-8644
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101035451174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
B06936Medicare UPIN