Healthcare Provider Details

I. General information

NPI: 1679532907
Provider Name (Legal Business Name): DANIEL MARK SIEGEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 10/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

994 W JERICHO TPKE SUITE 103
SMITHTOWN NY
11787-3235
US

IV. Provider business mailing address

994 W JERICHO TPKE SUITE 103
SMITHTOWN NY
11787-3235
US

V. Phone/Fax

Practice location:
  • Phone: 631-864-6647
  • Fax: 631-864-6001
Mailing address:
  • Phone: 631-864-6647
  • Fax: 631-864-6001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number150510
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number150510
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number150510
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number150510
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: