Provider Demographics
NPI:1043268204
Name:SPIVEY, MARK ALAN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:SPIVEY
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 1:1820 PRESTON PARK BLVD
Mailing Address - Street 2:1825
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-3656
Mailing Address - Country:US
Mailing Address - Phone:972-867-7862
Mailing Address - Fax:972-612-1623
Practice Address - Street 1:3901 W 15TH ST
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075
Practice Address - Country:US
Practice Address - Phone:972-596-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE66322085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX83R220OtherCOLLIN COUNTY PTAN
TX129787103Medicaid
TX129787103Medicaid