Provider Demographics
NPI:1831353788
Name:SPACKEY, JUSTIN (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:SPACKEY
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 1:586 OAK ST
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-4210
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2160 S FIRST AVE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-216-1084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1250520162085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology