Provider Demographics
NPI:1285614016
Name:SIEGEL, MARK SAMUEL (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:SAMUEL
Last Name:SIEGEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 HIGH TIDE DR
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29906-5221
Mailing Address - Country:US
Mailing Address - Phone:843-525-1500
Mailing Address - Fax:843-525-6107
Practice Address - Street 1:111 HIGH TIDE DR
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29906-5221
Practice Address - Country:US
Practice Address - Phone:843-525-1500
Practice Address - Fax:843-525-6107
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23932207W00000X
LAMD200210207W00000X
FLME94788207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I06197Medicare UPIN