Provider Demographics
NPI:1437152519
Name:SPATOLA, MARK A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:SPATOLA
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:2021 KINGSLEY AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-5128
Mailing Address - Country:US
Mailing Address - Phone:904-276-3376
Mailing Address - Fax:904-276-5308
Practice Address - Street 1:2021 KINGSLEY AVE
Practice Address - Street 2:STE 101
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5128
Practice Address - Country:US
Practice Address - Phone:904-276-3376
Practice Address - Fax:904-276-5308
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME0053729207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL049305800Medicaid
FL07610Medicare ID - Type UnspecifiedPROVIDER NUMBER
FL049305800Medicaid