Provider Demographics
NPI:1023145687
Name:SIEGEL, JOSEPH G (O D)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:G
Last Name:SIEGEL
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13350 VENTURA BLVD
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-3939
Mailing Address - Country:US
Mailing Address - Phone:818-788-1770
Mailing Address - Fax:
Practice Address - Street 1:13350 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423-3939
Practice Address - Country:US
Practice Address - Phone:818-788-1770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 7350 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3803OtherMESC
CASD0073500Medicaid
CA3843714Medicaid
CA3843714Medicaid