Provider Demographics
NPI:1306909445
Name:SPENGEL, DAVID THOMAS (OD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:THOMAS
Last Name:SPENGEL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13241 VILLAGE CT
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60445-1309
Mailing Address - Country:US
Mailing Address - Phone:708-597-2577
Mailing Address - Fax:
Practice Address - Street 1:1600 N STATE ROUTE 50
Practice Address - Street 2:RM 580 NORTHFIELD SQUARE
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-9307
Practice Address - Country:US
Practice Address - Phone:815-935-0404
Practice Address - Fax:815-935-0489
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008563152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL080337Medicare UPIN
IL579270082, 579260066Medicare PIN