Basic Information
| Provider Information | |||||||||
| NPI: | 1023173408 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARVIN L SPONAUGLE MD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 864091 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328864091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3528678898 | ||||||||
| FaxNumber: | 3527326282 | ||||||||
| Practice Location | |||||||||
| Address1: | 1395 S PINELLAS AVE | ||||||||
| Address2: | |||||||||
| City: | TARPON SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346893790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3528678898 | ||||||||
| FaxNumber: | 3527326282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2006 | ||||||||
| LastUpdateDate: | 09/12/2007 | ||||||||
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| AuthorizedOfficialLastName: | SPONAUGLE | ||||||||
| AuthorizedOfficialFirstName: | MARVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3528678898 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | ME45587 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 62590 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER |