Basic Information
| Provider Information | |||||||||
| NPI: | 1104814235 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SPENCER | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 SOUTHHALL LN | ||||||||
| Address2: | STE 300 | ||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327517172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078752080 | ||||||||
| FaxNumber: | 4076503455 | ||||||||
| Practice Location | |||||||||
| Address1: | 1617 TAMIAMI TRL | ||||||||
| Address2: | |||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339481040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9416132400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 05/10/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | ME0047672 | FL | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 5872736 | 01 | FL | AETNA | OTHER | 08153 | 01 | FL | BLUE CROSS/BLUE SHIELD | OTHER | 6417334 | 01 | FL | CIGNA | OTHER | 1255052 | 01 | FL | UHC | OTHER |