Provider Demographics
NPI:1316677875
Name:FAIRGRIEVE, SPENCER LACY (OD)
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:LACY
Last Name:FAIRGRIEVE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19255 CONDOR WAY
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:96022-8817
Mailing Address - Country:US
Mailing Address - Phone:530-526-2332
Mailing Address - Fax:
Practice Address - Street 1:33 W 42ND ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-8005
Practice Address - Country:US
Practice Address - Phone:212-938-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-16
Last Update Date:2022-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NYTUV009641152W00000X
NY009641152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program