1942378724 NPI number — GREGORY C SPAIN DPM

Table of content: GREGORY C SPAIN DPM (NPI 1942378724)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942378724 NPI number — GREGORY C SPAIN DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPAIN
Provider First Name:
GREGORY
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942378724
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/21/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11323 REFLECTION ISLES BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33912-8919
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-919-6896
Provider Business Mailing Address Fax Number:
239-219-6158

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11323 REFLECTION ISLES BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33912
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-919-6896
Provider Business Practice Location Address Fax Number:
239-219-6158
Provider Enumeration Date:
12/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  PO3323 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 413476 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 302558 . This is a "HEALTH AMERICA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2082528 . This is a "AETNA USHC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 004057100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3014221 . This is a "CIGNA HEALTHCARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 116378800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com