Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | MS023222 | MI |
NPI | 1003905712 |
---|---|
Provider Name | Marvin David Siegel |
First Address | Waterford, MI 48328-3735 |
Second Address | Waterford, MI 48328-3735 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/10/2006 |
Last Update Date | 28/01/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1007570 | (05) | MI |
B44195 | (02) |