Provider Demographics
NPI:1750564407
Name:SPANOGLE, JOSHUA PAUL (MD)
Entity type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:PAUL
Last Name:SPANOGLE
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 1:2290 SACRAMENTO ST
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-2929
Mailing Address - Country:US
Mailing Address - Phone:707-643-5785
Mailing Address - Fax:707-643-8810
Practice Address - Street 1:2290 SACRAMENTO ST
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-2929
Practice Address - Country:US
Practice Address - Phone:707-643-5785
Practice Address - Fax:707-643-8810
Is Sole Proprietor?:No
Enumeration Date:2007-12-17
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN51287207N00000X
CAA116055207ND0101X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP00773912OtherMEDICARE, RAILROAD
MNENROLLEDMedicaid
MNENROLLEDMedicaid