Provider Demographics
NPI:1700933884
Name:SIEGEL, JOHN EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EDWARD
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 1:2901 SUSSEX ST APT A
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-4964
Mailing Address - Country:US
Mailing Address - Phone:252-756-1563
Mailing Address - Fax:
Practice Address - Street 1:1001 E. FIFTH ST.
Practice Address - Street 2:EAST CAROLINA UNIV.
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858
Practice Address - Country:US
Practice Address - Phone:252-328-6841
Practice Address - Fax:252-328-4007
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15179207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCE70006Medicare UPIN