Provider Demographics
NPI:1427139252
Name:SIEGEL, ELIOT BRUCE (MD)
Entity type:Individual
Prefix:
First Name:ELIOT
Middle Name:BRUCE
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 1:1301 20TH STREET
Mailing Address - Street 2:SUITE 260
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404
Mailing Address - Country:US
Mailing Address - Phone:310-829-1224
Mailing Address - Fax:310-315-0133
Practice Address - Street 1:200 STEIN PLZ
Practice Address - Street 2:1-340
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-0001
Practice Address - Country:US
Practice Address - Phone:310-825-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39748207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G397480Medicaid
G39748AMedicare ID - Type Unspecified
CADC179YMedicare PIN
CA00G397480Medicaid