Provider Demographics
NPI:1275559163
Name:SPISAK, LORI DIANE (MD)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:DIANE
Last Name:SPISAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:D
Other - Last Name:WYLIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:102 HANDLEY PARK CT
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-1769
Mailing Address - Country:US
Mailing Address - Phone:919-734-3344
Mailing Address - Fax:919-735-3025
Practice Address - Street 1:102 HANDLEY PARK CT
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-1768
Practice Address - Country:US
Practice Address - Phone:919-734-3344
Practice Address - Fax:919-735-3025
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2024-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2022-00284207V00000X
MI4301077897207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
156058OtherGREAT LAKES HEALTH PLAN
MI700G410560OtherBLUE CROSS
160G360190OtherBCBSM GROUP PIN
160G360190OtherBCBSM GROUP PIN
MI700G410560OtherBLUE CROSS
I61880Medicare UPIN