Provider Demographics
NPI:1114218708
Name:BRIAN SPORE DO PA
Entity Type:Organization
Organization Name:BRIAN SPORE DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DO
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SPORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-634-2231
Mailing Address - Street 1:3804 S MEDFORD DR
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75901-5780
Mailing Address - Country:US
Mailing Address - Phone:936-634-2231
Mailing Address - Fax:936-634-8012
Practice Address - Street 1:3804 S MEDFORD DR
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75901-5780
Practice Address - Country:US
Practice Address - Phone:936-634-2231
Practice Address - Fax:936-634-8012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-29
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5703305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX092514101Medicaid
TX092514101Medicaid
TXH17195Medicare UPIN