Provider Demographics
NPI:1053399311
Name:SPAIN, JON BARTON (DO)
Entity type:Individual
Prefix:DR
First Name:JON
Middle Name:BARTON
Last Name:SPAIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2223 NE 28TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76106-7418
Mailing Address - Country:US
Mailing Address - Phone:817-624-3211
Mailing Address - Fax:817-624-6554
Practice Address - Street 1:2223 NE 28TH ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76106-7478
Practice Address - Country:US
Practice Address - Phone:817-624-3211
Practice Address - Fax:817-625-9835
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-06
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF4554207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX091917701Medicaid
TX091917701Medicaid
TX00DG78Medicare ID - Type Unspecified