Provider Demographics
NPI:1235121047
Name:SPETKO, NICHOLAS III (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:SPETKO
Suffix:III
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 1:108 PROVIDENCE TRL
Mailing Address - Street 2:
Mailing Address - City:MT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-6578
Mailing Address - Country:US
Mailing Address - Phone:615-466-0041
Mailing Address - Fax:615-758-3791
Practice Address - Street 1:108 PROVIDENCE TRL
Practice Address - Street 2:
Practice Address - City:MT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-6578
Practice Address - Country:US
Practice Address - Phone:615-466-0041
Practice Address - Fax:615-758-3791
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-17
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN62678207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ545920601Medicaid
E95637Medicare UPIN
NJ545920601Medicaid