Basic Information
| Provider Information | |||||||||
| NPI: | 1427139252 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIEGEL | ||||||||
| FirstName: | ELIOT | ||||||||
| MiddleName: | BRUCE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 20TH STREET | ||||||||
| Address2: | SUITE 260 | ||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108291224 | ||||||||
| FaxNumber: | 3103150133 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 STEIN PLZ | ||||||||
| Address2: | 1-340 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900950001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108255000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 05/14/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | G39748 | CA | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 00G397480 | 05 | CA | MEDICAID |