Provider Demographics
NPI:1306880703
Name:SPAK, BRADLEY PHILIP (MD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:PHILIP
Last Name:SPAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16611 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98233-3823
Mailing Address - Country:US
Mailing Address - Phone:360-757-8839
Mailing Address - Fax:
Practice Address - Street 1:1415 E KINCAID ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4126
Practice Address - Country:US
Practice Address - Phone:360-428-2367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00018515207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1904200Medicaid
WA1904200Medicaid
WA8858014Medicare ID - Type Unspecified