Healthcare Provider Details

I. General information

NPI: 1588658744
Provider Name (Legal Business Name): WAYNE T SPEARS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2005
Last Update Date: 02/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 EXCELSIOR BLVD
ST LOUIS PARK MN
55426-4702
US

IV. Provider business mailing address

6950 FRANCE AVE S # 200
EDINA MN
55435-2008
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-6032
  • Fax: 952-993-5512
Mailing address:
  • Phone: 952-920-4915
  • Fax: 952-915-6091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number33410
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: