Basic Information
Provider Information
NPI: 1003012188
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SPADER
FirstName: HEATHER
MiddleName: STEVENS
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: STEVENS
OtherFirstName: HEATHER
OtherMiddleName: LYNN
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType: 1
Mailing Information
Address1: 2900 CORPORATE WAY
Address2: DOOR D
City: MIRAMAR
State: FL
PostalCode: 330253925
CountryCode: US
TelephoneNumber: 9542765685
FaxNumber: 9549857074
Practice Location
Address1: 1150 N 35TH AVE STE 520
Address2:  
City: HOLLYWOOD
State: FL
PostalCode: 33021
CountryCode: US
TelephoneNumber: 9542653500
FaxNumber: 9549854230
Other Information
ProviderEnumerationDate: 06/25/2007
LastUpdateDate: 04/03/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 04/03/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207T00000XME 123879FLY Allopathic & Osteopathic PhysiciansNeurological Surgery 

ID Information
IDTypeStateIssuerDescription
01534510005FL MEDICAID


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