Provider Demographics
NPI:1235421033
Name:SPISAK-MOSHER, JUSTINE DIANE (DO)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:DIANE
Last Name:SPISAK-MOSHER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:856-355-0340
Mailing Address - Fax:
Practice Address - Street 1:1001 ROUTE 73 N UPPR LEVELA
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-4524
Practice Address - Country:US
Practice Address - Phone:856-988-3444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-11
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS0176462084N0400X
NVDO22302084N0400X
ORDO1955652084N0400X
NJ25MB117420002084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology