Provider Demographics
NPI:1841256237
Name:SPORE, JAN (MD)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:SPORE
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 1:4750 E GALBRAITH RD
Mailing Address - Street 2:STE. 207
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45236-6705
Mailing Address - Country:US
Mailing Address - Phone:513-686-4840
Mailing Address - Fax:513-686-4848
Practice Address - Street 1:4750 E GALBRAITH RD
Practice Address - Street 2:STE. 207
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45236-6705
Practice Address - Country:US
Practice Address - Phone:513-686-4840
Practice Address - Fax:513-686-4848
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35047408S207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64789019Medicaid
OH0496011Medicaid
OHP00919599OtherMEDICARE RR
OH0496011Medicaid
OH0513226Medicare PIN