Provider Demographics
NPI:1568464501
Name:SPEARS, REGINA LYNNE (DPM)
Entity Type:Individual
Prefix:DR
First Name:REGINA
Middle Name:LYNNE
Last Name:SPEARS
Suffix:
Gender:F
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 2078
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49081-2078
Mailing Address - Country:US
Mailing Address - Phone:269-639-1115
Mailing Address - Fax:269-639-2525
Practice Address - Street 1:10570 BLUE STAR M HWY
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-8923
Practice Address - Country:US
Practice Address - Phone:269-639-1115
Practice Address - Fax:269-639-2525
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001629213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3259601Medicaid
MI2783207Medicaid
MI0M26980Medicare ID - Type Unspecified
MI3259601Medicaid