1497861587 NPI number — DR. JUDSON LEWIS SIEGEL DPM

Table of content: DR. JUDSON LEWIS SIEGEL DPM (NPI 1497861587)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497861587 NPI number — DR. JUDSON LEWIS SIEGEL DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIEGEL
Provider First Name:
JUDSON
Provider Middle Name:
LEWIS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497861587
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 MATTHEW ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CUMBERLAND
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02864
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-475-3531
Provider Business Mailing Address Fax Number:
508-460-9728

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
340 MAPLE ST
Provider Second Line Business Practice Location Address:
STE 405
Provider Business Practice Location Address City Name:
MARLBOROUGH
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01752
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-481-3659
Provider Business Practice Location Address Fax Number:
508-460-9728
Provider Enumeration Date:
08/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  2090 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0316610 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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