Provider Demographics
NPI:1417021007
Name:SPADES, SEBASTIAN A III (MD)
Entity Type:Individual
Prefix:
First Name:SEBASTIAN
Middle Name:A
Last Name:SPADES
Suffix:III
Gender:M
Credentials:MD
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 719
Mailing Address - Street 2:
Mailing Address - City:WALNUT RIDGE
Mailing Address - State:AR
Mailing Address - Zip Code:72476-0719
Mailing Address - Country:US
Mailing Address - Phone:870-886-3543
Mailing Address - Fax:870-886-3252
Practice Address - Street 1:1210 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WALNUT RIDGE
Practice Address - State:AR
Practice Address - Zip Code:72476-1005
Practice Address - Country:US
Practice Address - Phone:870-886-3543
Practice Address - Fax:870-886-3252
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4530207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR55054OtherBLUE CROSS BLUE SHIELD
AR55054Medicare ID - Type Unspecified
AR55054OtherBLUE CROSS BLUE SHIELD