Healthcare Provider Details

I. General information

NPI: 1679757918
Provider Name (Legal Business Name): DR ALAN H SIEGEL P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2007
Last Update Date: 10/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10692 S US HIGHWAY 1 SUITE B
PORT ST LUCIE FL
34952-6408
US

IV. Provider business mailing address

10692 S US HIGHWAY 1 SUITE B
PORT ST LUCIE FL
34952-6408
US

V. Phone/Fax

Practice location:
  • Phone: 772-335-5006
  • Fax: 772-335-4672
Mailing address:
  • Phone: 772-335-5006
  • Fax: 772-335-4672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC1190
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberFL1190
License Number StateFL

VIII. Authorized Official

Name: DR. ALAN HOWARD SIEGEL
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 772-335-5006