Provider Demographics
NPI:1427059930
Name:SIEMONS, GARY OTTO (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:OTTO
Last Name:SIEMONS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:402 LIPPINCOTT DR
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4112
Mailing Address - Country:US
Mailing Address - Phone:856-782-3300
Mailing Address - Fax:856-762-1751
Practice Address - Street 1:502 CENTENNIAL BLVD
Practice Address - Street 2:SUITE 5
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043
Practice Address - Country:US
Practice Address - Phone:856-429-8030
Practice Address - Fax:856-428-2718
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA04074600208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1655507Medicaid
NJ1655507Medicaid
403879SLRMedicare ID - Type Unspecified