Provider Demographics
NPI:1720154818
Name:SPENCER, GARY C (OD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:C
Last Name:SPENCER
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 1:2624 OXFORD CIR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-2447
Mailing Address - Country:US
Mailing Address - Phone:734-369-4833
Mailing Address - Fax:
Practice Address - Street 1:3106 GLADE ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-2706
Practice Address - Country:US
Practice Address - Phone:231-733-9669
Practice Address - Fax:231-733-9669
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002683152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI450463757OtherTAX ID # PRIORITY HEALTH
MI71020000F16521OtherBCBS
MI900F165210OtherBCBS
MI900F165210OtherBLUE CARE NETWORK