Provider Demographics
NPI:1689679425
Name:SPAGNOLO, BRAD VINCENT (MD)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:VINCENT
Last Name:SPAGNOLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:200 HOSPITAL DR
Mailing Address - Street 2:STE 600
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-5865
Mailing Address - Country:US
Mailing Address - Phone:410-766-3937
Mailing Address - Fax:410-761-4386
Practice Address - Street 1:200 HOSPITAL DR
Practice Address - Street 2:STE 600
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-5865
Practice Address - Country:US
Practice Address - Phone:410-766-3937
Practice Address - Fax:410-761-4386
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD0056098207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD111002100Medicaid
MD111002100Medicaid
MD494LMedicare PIN
MDH16460Medicare UPIN