Provider Demographics
NPI:1538163290
Name:SIEGEL, AUDRA ROCHELLE (DPM)
Entity type:Individual
Prefix:DR
First Name:AUDRA
Middle Name:ROCHELLE
Last Name:SIEGEL
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 NORTH RD STE 304
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-1173
Mailing Address - Country:US
Mailing Address - Phone:845-451-7251
Mailing Address - Fax:845-471-7372
Practice Address - Street 1:696 DUTCHESS TPKE STE M
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603-6429
Practice Address - Country:US
Practice Address - Phone:845-464-0630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY65 006034213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1235164997OtherNPI GROUP ID
AS00573K10OtherBLUE CROSS BLUE SHIELD PIN/IDENTIFIER
10111279OtherCDPHP PIN/IDENTIFIER
200053170OtherMVP HEALTHCARE GROUP ID
65 006034OtherNYS PROFESSIONAL LICENSE
NY02754227Medicaid
4148374OtherMVP HEALTHCARE PIN
0488940001Medicare Oscar/Certification
0488940001Medicare NSC
PJ642PAE21Medicare PIN
200053170OtherMVP HEALTHCARE GROUP ID
65 006034OtherNYS PROFESSIONAL LICENSE