Provider Demographics
NPI:1063421360
Name:SIEGEL, MICHAEL EDWARD (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EDWARD
Last Name:SIEGEL
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 1:564 NORTHWEST MALL
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77092-8544
Mailing Address - Country:US
Mailing Address - Phone:713-681-2467
Mailing Address - Fax:
Practice Address - Street 1:564 NORTHWEST MALL
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77092-8544
Practice Address - Country:US
Practice Address - Phone:713-681-2467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2141152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143837OtherCOLEVISION
TXG000E92A2Medicaid
TX16114OtherSPECTERA
TX902815OtherBLOCK
TX6306OtherAVESIS
TX143837OtherCOLEVISION
TXG000E92A2Medicaid