Provider Demographics
NPI:1194111047
Name:SPIEWAK, MEGAN ROBERTA (MD)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:ROBERTA
Last Name:SPIEWAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:ROBERTA
Other - Last Name:THIES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:813-974-2201
Mailing Address - Fax:
Practice Address - Street 1:17 DAVIS BLVD
Practice Address - Street 2:SUITE 308
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3475
Practice Address - Country:US
Practice Address - Phone:813-259-8725
Practice Address - Fax:813-259-8792
Is Sole Proprietor?:No
Enumeration Date:2015-04-07
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME141043208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSO5L7OtherBLUE CROSS BLUE SHIELD
FL103598700Medicaid
FLSO5L7OtherBLUE CROSS BLUE SHIELD