Provider Demographics
NPI:1942378724
Name:SPAIN, GREGORY C (DPM)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:C
Last Name:SPAIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11323 REFLECTION ISLES BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-8919
Mailing Address - Country:US
Mailing Address - Phone:239-919-6896
Mailing Address - Fax:239-219-6158
Practice Address - Street 1:11323 REFLECTION ISLES BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912
Practice Address - Country:US
Practice Address - Phone:239-919-6896
Practice Address - Fax:239-219-6158
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3323213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA413476OtherBLUE SHIELD
PA302558OtherHEALTH AMERICA
PA2082528OtherAETNA USHC
FL004057100Medicaid
PA3014221OtherCIGNA HEALTHCARE
PA413476OtherBLUE SHIELD
PA3014221OtherCIGNA HEALTHCARE