Healthcare Provider Details

I. General information

NPI: 1184165805
Provider Name (Legal Business Name): MARK SPAW M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2017
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 E 32ND ST
JOPLIN MO
64804-4103
US

IV. Provider business mailing address

1920 E 32ND ST
JOPLIN MO
64804-4103
US

V. Phone/Fax

Practice location:
  • Phone: 417-781-4613
  • Fax: 417-781-0805
Mailing address:
  • Phone: 417-781-4613
  • Fax: 417-781-0805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD-20206
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number105017
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number2025039094
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: