Healthcare Provider Details

I. General information

NPI: 1912430638
Provider Name (Legal Business Name): JACOB SIEGEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2017
Last Update Date: 05/13/2021
Certification Date: 05/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 SYOSSET WOODBURY RD
WOODBURY NY
11797-1215
US

IV. Provider business mailing address

333 CEDAR ST, PO BOX 208059
NEW HAVEN CT
06520
US

V. Phone/Fax

Practice location:
  • Phone: 516-476-4071
  • Fax:
Mailing address:
  • Phone: 203-785-4092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number67573
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: