Provider Demographics
NPI:1063575199
Name:SPAK, CEDRIC W (MD)
Entity type:Individual
Prefix:DR
First Name:CEDRIC
Middle Name:W
Last Name:SPAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 OAKDALE AVE N
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-2926
Mailing Address - Country:US
Mailing Address - Phone:763-520-5200
Mailing Address - Fax:763-257-8356
Practice Address - Street 1:1025 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3013
Practice Address - Country:US
Practice Address - Phone:817-810-9810
Practice Address - Fax:817-840-9815
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00043412207RI0200X
TXL1206207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8J4777OtherMEDICARE
TX145478703Medicaid
TXH42385Medicare UPIN