Provider Demographics
NPI:1144301474
Name:SIEGELBAUM, GARY (OD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:SIEGELBAUM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61-30A 190 ST
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-2720
Mailing Address - Country:US
Mailing Address - Phone:718-454-8484
Mailing Address - Fax:718-454-8910
Practice Address - Street 1:61-30A 190 ST
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-2720
Practice Address - Country:US
Practice Address - Phone:718-454-8484
Practice Address - Fax:718-454-8910
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV0043351152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU38175Medicare UPIN
NY00718Medicare PIN