Provider Demographics
NPI:1740384924
Name:SIEGEL, FRED S (MD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:S
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 1:540 SAYBROOK RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4711
Mailing Address - Country:US
Mailing Address - Phone:860-347-7491
Mailing Address - Fax:860-346-2118
Practice Address - Street 1:540 SAYBROOK RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-4711
Practice Address - Country:US
Practice Address - Phone:860-347-7491
Practice Address - Fax:860-346-2118
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT025665207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001256650Medicaid
B38478Medicare UPIN
CT001256650Medicaid