Provider Demographics
NPI:1245268093
Name:SIEGEL, BONITA HAZEL (MD)
Entity type:Individual
Prefix:DR
First Name:BONITA
Middle Name:HAZEL
Last Name:SIEGEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 SAINT JAMES PL
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-2302
Mailing Address - Country:US
Mailing Address - Phone:718-857-2716
Mailing Address - Fax:718-374-5346
Practice Address - Street 1:210 SAINT JAMES PL
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-2302
Practice Address - Country:US
Practice Address - Phone:718-857-2716
Practice Address - Fax:718-374-5346
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD051622L2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001719257Medicaid
G64271Medicare UPIN
PA001719257Medicaid