Provider Demographics
NPI:1326143439
Name:SPOO, CHARISA M (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARISA
Middle Name:M
Last Name:SPOO
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 1:4440 W 95TH ST
Mailing Address - Street 2:RADIOLOGY DEPARTMENT
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453
Mailing Address - Country:US
Mailing Address - Phone:708-684-8000
Mailing Address - Fax:
Practice Address - Street 1:4440 W 95TH
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453
Practice Address - Country:US
Practice Address - Phone:708-684-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360785152085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036078515Medicaid
ILP00110671OtherRAILROAD
IL1618334OtherBCBS ID
L94019Medicare PIN
E42130Medicare UPIN