Provider Demographics
NPI:1770512006
Name:SIEGEL, JACK L (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:L
Last Name:SIEGEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5716 CLEVELAND ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-1784
Mailing Address - Country:US
Mailing Address - Phone:757-502-8570
Mailing Address - Fax:757-961-9767
Practice Address - Street 1:5716 CLEVELAND ST
Practice Address - Street 2:SUITE 200
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-1784
Practice Address - Country:US
Practice Address - Phone:757-502-8570
Practice Address - Fax:757-961-9767
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101042155207X00000X, 207XX0005X, 207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA200000558Medicare ID - Type Unspecified
VAE19463Medicare UPIN