Provider Demographics
NPI:1326299512
Name:BIDELSPACH, JOHN SAMUEL (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:SAMUEL
Last Name:BIDELSPACH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2497
Mailing Address - Street 2:
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34688-2497
Mailing Address - Country:US
Mailing Address - Phone:866-362-3668
Mailing Address - Fax:866-596-7195
Practice Address - Street 1:487 BAYOU VILLAGE DR
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-3607
Practice Address - Country:US
Practice Address - Phone:866-362-3668
Practice Address - Fax:866-596-7195
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-06
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP0002345213ES0103X
GA657213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU25281Medicare UPIN