Healthcare Provider Details

I. General information

NPI: 1285677997
Provider Name (Legal Business Name): FREDERICK SIEGEL OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 OLD GALLOWS RD, #100
VIENNA VA
22182
US

IV. Provider business mailing address

901 N. STUART ST, #210
ARLINGTON VA
22203
US

V. Phone/Fax

Practice location:
  • Phone: 703-847-8899
  • Fax: 703-847-5177
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618000185
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: