Provider Demographics
NPI:1497708200
Name:PISPIDIKIS, JOHN (NP-C, DC, DACNB)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:PISPIDIKIS
Suffix:
Gender:M
Credentials:NP-C, DC, DACNB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2243 E 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-5644
Mailing Address - Country:US
Mailing Address - Phone:214-717-1859
Mailing Address - Fax:586-573-8100
Practice Address - Street 1:2243 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-5644
Practice Address - Country:US
Practice Address - Phone:214-717-1859
Practice Address - Fax:586-573-8100
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704287416363L00000X
TXDC8263111N00000X
MI2301009328111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No111N00000XChiropractic ProvidersChiropractor
No111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX002102403Medicaid
TX8R1720OtherBCBS
TX8P2242OtherBCBS
TX8P5600OtherBCBS
TX8M8882OtherBCBS
TX8R1720OtherBCBS
MIU76018Medicare UPIN
TX8P5600OtherBCBS
TX8C7423Medicare ID - Type Unspecified
TX8F1959Medicare ID - Type Unspecified
TX8B6629Medicare ID - Type Unspecified