Provider Demographics
NPI:1194780759
Name:SPENCER, MATTHEW W (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:W
Last Name:SPENCER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 ALUMNI AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-2333
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 ATWELL RD
Practice Address - Street 2:
Practice Address - City:COOPERSTOWN
Practice Address - State:NY
Practice Address - Zip Code:13326-1301
Practice Address - Country:US
Practice Address - Phone:607-547-3909
Practice Address - Fax:607-547-6325
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI195932085R0202X
NY2321872085R0202X
MA2177152085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02574216Medicaid
NYRA2884Medicare ID - Type UnspecifiedUPSTATE
NY02574216Medicaid