Provider Demographics
NPI:1740284280
Name:SPAL, MARK BRUCE (DPM,RPH)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:BRUCE
Last Name:SPAL
Suffix:
Gender:M
Credentials:DPM,RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:23 SPRINGHILL ROAD
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:NJ
Mailing Address - Zip Code:07869-4324
Mailing Address - Country:US
Mailing Address - Phone:973-895-4857
Mailing Address - Fax:973-933-2030
Practice Address - Street 1:23 SPRINGHILL ROAD
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:NJ
Practice Address - Zip Code:07869-4324
Practice Address - Country:US
Practice Address - Phone:973-895-4857
Practice Address - Fax:973-933-2030
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00213800213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ480025935OtherRAILRAOD MEDICARE
NJ5447704Medicaid
NJ725763Medicare PIN
NJ5447704Medicaid
NJU32255Medicare UPIN