Provider Demographics
NPI:1558845396
Name:SPELKE, CRAIG (OD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:
Last Name:SPELKE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11823 FARMLAND DR
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4303
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11823 FARMLAND DR
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-4303
Practice Address - Country:US
Practice Address - Phone:301-442-7567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCOP1000389152W00000X
VA0618002687152W00000X
MDTA2648152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCOP1000389OtherDC OPTOMETRY LICENSE
VA0618002687OtherVIRGINIA OPTOMETRY LICENSE
MDTA2648OtherMARYLAND OPTOMETRY LICENSE NUMBER