Provider Demographics
NPI:1659454221
Name:SPALDING, PATRICK JACKSON (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:JACKSON
Last Name:SPALDING
Suffix:
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 1:2 JAMES WAY
Mailing Address - Street 2:SUITE 106
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-4973
Mailing Address - Country:US
Mailing Address - Phone:805-773-3060
Mailing Address - Fax:805-269-0026
Practice Address - Street 1:2 JAMES WAY
Practice Address - Street 2:SUITE 106
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-4973
Practice Address - Country:US
Practice Address - Phone:805-773-3060
Practice Address - Fax:805-269-0026
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG83816207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G838160Medicaid
CA00G838160Medicaid
CAG40776Medicare UPIN