Provider Demographics
NPI:1649322595
Name:SIEGEL, MARK (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
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 1:1220 DEWEY AVE.
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-2504
Mailing Address - Country:US
Mailing Address - Phone:414-454-6779
Mailing Address - Fax:414-454-6450
Practice Address - Street 1:1220 DEWEY AVE.
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-2504
Practice Address - Country:US
Practice Address - Phone:414-454-6566
Practice Address - Fax:414-454-6522
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI232420202084P0800X, 2084P0804X
WI23242-0202084P0800X
WI23240-0202084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30525800Medicaid
WIB56605Medicare UPIN
WI68225Medicare ID - Type Unspecified
WI01175-0039Medicare PIN