Provider Demographics
NPI:1487725024
Name:SIEGEL, BENNETT E (DC)
Entity type:Individual
Prefix:
First Name:BENNETT
Middle Name:E
Last Name:SIEGEL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3801
Mailing Address - Country:US
Mailing Address - Phone:860-674-1992
Mailing Address - Fax:860-674-9664
Practice Address - Street 1:28 E MAIN ST
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3801
Practice Address - Country:US
Practice Address - Phone:860-674-1992
Practice Address - Fax:860-674-9664
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT291111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT742980OtherCTCARE
CT742980OtherCTCARE