Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RI0200X | Infectious Disease | L1206 | TX |
N | 207RI0200X | Infectious Disease | MD00043412 | WA |
NPI | 1063575199 |
---|---|
Provider Name | Dr. Cedric W. Spak |
First Address | Robbinsdale, MN 55422-2926 |
Second Address | Fort Worth, TX 76104-3013 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/12/2006 |
Last Update Date | 29/10/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
145478703 | (05) | TX |
8J4777 | MEDICARE (01) | TX |
H42385 | (02) | TX |