Healthcare Provider Details

I. General information

NPI: 1578645453
Provider Name (Legal Business Name): JAY ANDREW SIEGALL O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3990 NESCONSETT HWY
SOUTH SETAUKET NY
11733
US

IV. Provider business mailing address

6 DAVIS ST
MELVILLE NY
11747-1403
US

V. Phone/Fax

Practice location:
  • Phone: 631-474-3805
  • Fax: 631-474-3815
Mailing address:
  • Phone: 631-549-1647
  • Fax: 631-474-3815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT-005486-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: