Provider Demographics
NPI:1033195656
Name:SPANO, DENNIS CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:CHARLES
Last Name:SPANO
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 1:1200 GRANT BLVD W
Mailing Address - Street 2:
Mailing Address - City:WABASHA
Mailing Address - State:MN
Mailing Address - Zip Code:55981-1042
Mailing Address - Country:US
Mailing Address - Phone:651-565-5600
Mailing Address - Fax:
Practice Address - Street 1:500 W GRANT ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:MN
Practice Address - Zip Code:55041-1143
Practice Address - Country:US
Practice Address - Phone:651-345-3321
Practice Address - Fax:651-345-1151
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN36426207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
49A86SPOtherBCBS
118169OtherUCARE
MH9101008904OtherPREFERRED ONE
080125255OtherRAILROAD MEDICARE
MN925515000Medicaid
0113159OtherMEDICA
F71866Medicare UPIN
080125255OtherRAILROAD MEDICARE