Provider Demographics
NPI:1619931870
Name:SIEGEL, TIMOTHY R (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:R
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 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-6068
Mailing Address - Fax:503-494-3495
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239
Practice Address - Country:US
Practice Address - Phone:503-494-6068
Practice Address - Fax:503-494-3495
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH15327208600000X, 2086H0002X
VA0101257693208600000X, 2086H0002X
ORMD1838912086H0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086H0002XAllopathic & Osteopathic PhysiciansSurgeryHospice and Palliative Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3073841Medicaid
NY01929280Medicaid
NHAA224057OtherHARVARD PILGRIM
NH32000782Medicaid
NH002323701OtherMEDICARE PTAN
VT1019444Medicaid
VT1019444Medicaid
NYC06639Medicare UPIN