Healthcare Provider Details

I. General information

NPI: 1316926462
Provider Name (Legal Business Name): GEORGE SIEGEL M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2006
Last Update Date: 08/18/2024
Certification Date: 08/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W COAST HWY STE G
NEWPORT BEACH CA
92663-5000
US

IV. Provider business mailing address

481 E 19TH ST
COSTA MESA CA
92627-2313
US

V. Phone/Fax

Practice location:
  • Phone: 949-650-0456
  • Fax: 949-650-0921
Mailing address:
  • Phone: 949-650-0456
  • Fax: 949-650-0921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number6791
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: