Provider Demographics
NPI:1255416624
Name:SIEGEL, MARTIN ERNEST (MD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:ERNEST
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 1:310 LANGDON ST STE 5
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-2795
Mailing Address - Country:US
Mailing Address - Phone:606-678-7664
Mailing Address - Fax:606-678-9139
Practice Address - Street 1:310 LANGDON ST STE 5
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2795
Practice Address - Country:US
Practice Address - Phone:606-678-7664
Practice Address - Fax:606-678-9139
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY32535174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64325350Medicaid
KY1641501Medicare ID - Type UnspecifiedPROVIDER NUMBER
KY64325350Medicaid