Provider Demographics
NPI:1639208861
Name:SIEGEL, BURTON EVERETT (MD)
Entity Type:Individual
Prefix:DR
First Name:BURTON
Middle Name:EVERETT
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 1:1121 JOHNSON FERRY ROAD
Mailing Address - Street 2:SUITE 330
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068
Mailing Address - Country:US
Mailing Address - Phone:770-971-1299
Mailing Address - Fax:
Practice Address - Street 1:1121 JOHNSON FERRY ROAD
Practice Address - Street 2:SUITE 330
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-5425
Practice Address - Country:US
Practice Address - Phone:770-971-1299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA022640207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD41911Medicare UPIN