Provider Demographics
NPI:1528053683
Name:SIESEL, ERIC
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:SIESEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3265 S. M-129
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783
Mailing Address - Country:US
Mailing Address - Phone:906-635-9347
Mailing Address - Fax:906-635-1113
Practice Address - Street 1:3265 S. M-129
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783
Practice Address - Country:US
Practice Address - Phone:906-635-9347
Practice Address - Fax:906-635-1113
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003938152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI944461338Medicaid
P00062822Medicare PIN
N62370001Medicare PIN
MI944461338Medicaid