Provider Demographics
NPI:1013923572
Name:SPOLAR, TRENTON JOHN (MD)
Entity Type:Individual
Prefix:
First Name:TRENTON
Middle Name:JOHN
Last Name:SPOLAR
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 1:29801 NE 254TH ST
Mailing Address - Street 2:PO BOX 369
Mailing Address - City:YACOLT
Mailing Address - State:WA
Mailing Address - Zip Code:98675
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 EAST 19TH, SECOND FLOOR
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058
Practice Address - Country:US
Practice Address - Phone:541-296-7585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22926207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A08087Medicare UPIN