Provider Demographics
NPI:1629044185
Name:SIEGEL, LANCE MITCHELL (MD)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:MITCHELL
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 1:1246 E ARROW HWY STE A
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4955
Mailing Address - Country:US
Mailing Address - Phone:909-931-9675
Mailing Address - Fax:909-931-3239
Practice Address - Street 1:1246 E ARROW HWY
Practice Address - Street 2:STE A
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4955
Practice Address - Country:US
Practice Address - Phone:909-931-9675
Practice Address - Fax:909-931-3239
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG72351207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G723510Medicaid
CA00G723510Medicaid
G07982Medicare UPIN