Provider Demographics
NPI:1811163207
Name:SIEGERT, CHARLES J (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:J
Last Name:SIEGERT
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:PSC 482 BOX 2608
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96362-2699
Mailing Address - Country:US
Mailing Address - Phone:903-257-1200
Mailing Address - Fax:
Practice Address - Street 1:50 PARK ST APT 35
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-6200
Practice Address - Country:US
Practice Address - Phone:617-935-3532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-05
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101248125208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery