Provider Demographics
NPI:1750542064
Name:SPAIN, BRETT MICHAEL (DO)
Entity type:Individual
Prefix:DR
First Name:BRETT
Middle Name:MICHAEL
Last Name:SPAIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 MERRICK RD
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-6231
Mailing Address - Country:US
Mailing Address - Phone:516-795-3033
Mailing Address - Fax:
Practice Address - Street 1:5500 MERRICK RD
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-6231
Practice Address - Country:US
Practice Address - Phone:516-795-3033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-19
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY254808207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program