Provider Demographics
NPI:1700861598
Name:SIEGEL, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
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 1:789 HOWARD AVE
Mailing Address - Street 2:FITKIN BUILDING, 2ND FLOOR
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1304
Mailing Address - Country:US
Mailing Address - Phone:203-785-4198
Mailing Address - Fax:203-737-5453
Practice Address - Street 1:789 HOWARD AVE
Practice Address - Street 2:FITKIN BUILDING, 2ND FLOOR
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1304
Practice Address - Country:US
Practice Address - Phone:203-785-4198
Practice Address - Fax:203-737-5453
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT033081207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001330810Medicaid
CT81000001Medicare ID - Type Unspecified
CT001330810Medicaid
F97014Medicare UPIN