Provider Demographics
NPI:1053726687
Name:SPIVA, JONATHAN (DC)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:SPIVA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MADILL
Mailing Address - State:OK
Mailing Address - Zip Code:73446-1489
Mailing Address - Country:US
Mailing Address - Phone:580-677-2627
Mailing Address - Fax:580-430-0595
Practice Address - Street 1:802 N 1ST ST
Practice Address - Street 2:
Practice Address - City:MADILL
Practice Address - State:OK
Practice Address - Zip Code:73446-1489
Practice Address - Country:US
Practice Address - Phone:580-677-2627
Practice Address - Fax:580-430-0595
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-23
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4124111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor