Provider Demographics
NPI:1679663918
Name:SIEGEL, MITCHELL J (DPM)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:J
Last Name:SIEGEL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 MAPLE DRIVE
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-1240
Mailing Address - Country:US
Mailing Address - Phone:516-482-0998
Mailing Address - Fax:516-482-0017
Practice Address - Street 1:32 MAPLE DRIVE
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-1240
Practice Address - Country:US
Practice Address - Phone:516-482-0998
Practice Address - Fax:516-482-0017
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN2782213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00405587Medicaid
P3600840OtherOXFORD
4286910001OtherDME
NYP30722Medicare ID - Type Unspecified
P3600840OtherOXFORD