Healthcare Provider Details

I. General information

NPI: 1558303727
Provider Name (Legal Business Name): EDWARD LEWIS SPELLMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 05/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000 BOULDER AVE
HIGHLAND CA
92346
US

IV. Provider business mailing address

1615 ORANGE TREE LN
REDLANDS CA
92374-4501
US

V. Phone/Fax

Practice location:
  • Phone: 909-862-1191
  • Fax:
Mailing address:
  • Phone: 909-786-0725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number031860
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: