Provider Demographics
NPI:1265591895
Name:SIEGEL, KIMBERLY LYNNE (MD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LYNNE
Last Name:SIEGEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4674 SNOW MESA DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-8615
Mailing Address - Country:US
Mailing Address - Phone:970-495-8450
Mailing Address - Fax:970-297-6599
Practice Address - Street 1:4674 SNOW MESA DR
Practice Address - Street 2:SUITE 200
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-8615
Practice Address - Country:US
Practice Address - Phone:970-495-8450
Practice Address - Fax:970-297-6599
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA849942083P0901X
MT125562083P0901X
390200000X
CODR.00557192083P0901X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO26780071Medicaid
CA00A849940Medicaid
C423870OtherNUID
CO26780071Medicaid
C423870OtherNUID