Provider Demographics
NPI:1750707972
Name:SPEARS, ERIC
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:SPEARS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 N FERDON BLVD
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-2157
Mailing Address - Country:US
Mailing Address - Phone:850-682-5354
Mailing Address - Fax:850-682-5354
Practice Address - Street 1:840 N FERDON BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-2157
Practice Address - Country:US
Practice Address - Phone:850-682-5354
Practice Address - Fax:850-682-5354
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-12
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLJB133879171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL691206100Medicaid