Provider Demographics
NPI:1093711657
Name:SPATAFORE, JACK ANTHONY (DPT/MS)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:ANTHONY
Last Name:SPATAFORE
Suffix:
Gender:M
Credentials:DPT/MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1751
Mailing Address - Country:US
Mailing Address - Phone:304-842-3137
Mailing Address - Fax:304-842-3138
Practice Address - Street 1:306 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1751
Practice Address - Country:US
Practice Address - Phone:304-842-3137
Practice Address - Fax:304-842-3138
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002038174400000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV01071873100OtherWV WORKERS' COMPENSATION
WV1382862OtherUMWA
WV7305012-001Medicaid
WVWV51916BOtherHEALTH PLAN
WV701615OtherAETNA
WV650023875OtherRAILROAD MEDICARE
WV010718731004OtherBLUE CROSS
WV135810OtherHEALTH ASSURANCE
WV398789OtherOPTIMUM CHOICE
WVSP4028274Medicare PIN
WVSP40282736Medicare PIN