Provider Demographics
NPI:1104814235
Name:SPENCER, STEPHEN A (MD PA)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:A
Last Name:SPENCER
Suffix:
Gender:M
Credentials:MD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 SOUTHHALL LN
Mailing Address - Street 2:STE 300
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7172
Mailing Address - Country:US
Mailing Address - Phone:407-875-2080
Mailing Address - Fax:407-650-3455
Practice Address - Street 1:1617 TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-1040
Practice Address - Country:US
Practice Address - Phone:941-613-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0047672207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5872736OtherAETNA
FL08153OtherBLUE CROSS/BLUE SHIELD
FL6417334OtherCIGNA
FL1255052OtherUHC
FL1255052OtherUHC
FL08153BMedicare PIN