Provider Demographics
NPI:1790761567
Name:SIEGEL, PHILIP SAMUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:SAMUEL
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 1:1636 GARY WAY
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-5960
Mailing Address - Country:US
Mailing Address - Phone:916-488-5193
Mailing Address - Fax:916-262-2133
Practice Address - Street 1:3250 MEADOWVIEW RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95832-1437
Practice Address - Country:US
Practice Address - Phone:916-262-2020
Practice Address - Fax:916-262-2031
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC36485171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA060000001956550000Medicare UPIN