Provider Demographics
NPI:1487690046
Name:SIEGEL, MARK PHILLIPS (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:PHILLIPS
Last Name:SIEGEL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 W MARYLAND AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015
Mailing Address - Country:US
Mailing Address - Phone:602-242-4100
Mailing Address - Fax:602-242-7965
Practice Address - Street 1:1820 W MARYLAND AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015
Practice Address - Country:US
Practice Address - Phone:602-242-4100
Practice Address - Fax:602-242-7965
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ2479207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZE18134Medicare UPIN