Provider Demographics
NPI:1316121015
Name:DAVID K. SPENCER, O.D.
Entity type:Organization
Organization Name:DAVID K. SPENCER, O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:O D
Authorized Official - Phone:618-439-7256
Mailing Address - Street 1:711 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:IL
Mailing Address - Zip Code:62812-1017
Mailing Address - Country:US
Mailing Address - Phone:618-439-7256
Mailing Address - Fax:618-439-7257
Practice Address - Street 1:711 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:IL
Practice Address - Zip Code:62812-1017
Practice Address - Country:US
Practice Address - Phone:618-439-7256
Practice Address - Fax:618-439-7257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007635152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046007635Medicaid
U25863Medicare UPIN
0252800001Medicare NSC
IL046007635Medicaid