MEDICARE: DR. CEDRIC W. SPAK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RI0200X	Infectious Disease Physician	MD00043412	WA
2	207RI0200X	Infectious Disease Physician	L1206	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8J4777	OTHER	TX	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063575199
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CEDRIC W. SPAK MD

Provider Business Mailing Address
First Line	:	3300 OAKDALE AVE N
Second Line	:
City	:	ROBBINSDALE
State	:	MN
Zip	:	55422-2926
Country	:	US
Telephone Number	:	763-520-5200
Fax Number	:	763-257-8356

Provider Business Practice Location Address
First Line	:	1025 COLLEGE AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3013
Country	:	US
Telephone Number	:	817-810-9810
Fax Number	:	817-840-9815

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/19/2006
Last Update Date	:	10/29/2018

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