Provider Demographics
NPI:1639137045
Name:SIEGEL, TINA M (OD)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:M
Last Name:SIEGEL
Suffix:
Gender:F
Credentials:OD
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Mailing Address - Street 1:2325 SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-2529
Mailing Address - Country:US
Mailing Address - Phone:252-451-5324
Mailing Address - Fax:252-451-5330
Practice Address - Street 1:775 W CORBETT AVE STE 1
Practice Address - Street 2:
Practice Address - City:SWANSBORO
Practice Address - State:NC
Practice Address - Zip Code:28584-8453
Practice Address - Country:US
Practice Address - Phone:910-326-3050
Practice Address - Fax:910-326-7088
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2017-03-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC1374152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890989HMedicaid
NCQ53150AMedicare PIN
NCU12114Medicare UPIN