Provider Demographics
NPI:1326184136
Name:SPINA, MARK (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:SPINA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 MILL ST
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:NY
Mailing Address - Zip Code:12754-2010
Mailing Address - Country:US
Mailing Address - Phone:845-292-8810
Mailing Address - Fax:845-295-9156
Practice Address - Street 1:21 MILL ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NY
Practice Address - Zip Code:12754-2010
Practice Address - Country:US
Practice Address - Phone:845-292-8810
Practice Address - Fax:845-295-9156
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX3711111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX20631Medicare ID - Type Unspecified