Provider Demographics
NPI:1053525170
Name:SPAK, ERIC WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:WILLIAM
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 1:301 FRANK H CUSHING WAY # 3A
Mailing Address - Street 2:
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913-4067
Mailing Address - Country:US
Mailing Address - Phone:671-687-6544
Mailing Address - Fax:
Practice Address - Street 1:301 FRANK H CUSHING WAY # 3A
Practice Address - Street 2:
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913-4067
Practice Address - Country:US
Practice Address - Phone:671-687-6544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUM15012085R0202X
GU247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
I49739Medicare UPIN
101298Medicare ID - Type Unspecified
GUBK491ZMedicare Oscar/Certification