Provider Demographics
NPI:1881705796
Name:SPITALIERI, JOHN (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:SPITALIERI
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 1:371 GARDEN ST # A-27
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-2914
Mailing Address - Country:US
Mailing Address - Phone:928-447-7463
Mailing Address - Fax:928-441-1777
Practice Address - Street 1:999 DIVISION ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1654
Practice Address - Country:US
Practice Address - Phone:928-447-7463
Practice Address - Fax:928-441-1777
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ007015207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0079700Medicaid
KY64128374Medicaid
CAGR0079700Medicaid
KY0316522Medicare PIN