Basic Information
Provider Information | |||||||||
NPI: | 1720196249 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SPEKTOR | ||||||||
FirstName: | IRENA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SPEVAK | ||||||||
OtherFirstName: | IRENA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3495 PIEDMONT ROAD NE | ||||||||
Address2: | NINE PIEDMONT CENTER | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303051796 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4043647000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2525 CUMBERLAND PARKWAY | ||||||||
Address2: | KAISER PERMANENTE CUMBERLAND MEDICAL CENTER | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 30339 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7704314330 | ||||||||
FaxNumber: | 7704314193 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/25/2006 | ||||||||
LastUpdateDate: | 02/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 053611 | GA | Y |   | Allopathic & Osteopathic Physicians | Dermatology |   |
ID Information
ID | Type | State | Issuer | Description | 610670993A | 05 | GA |   | MEDICAID |