Provider Demographics
NPI:1962152660
Name:VINES, SPENSER WALTER (DO)
Entity type:Individual
Prefix:
First Name:SPENSER
Middle Name:WALTER
Last Name:VINES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 NEW SCOTLAND AVENUE
Mailing Address - Street 2:DEPT. OF EMERGENCY MEDICINE
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208
Mailing Address - Country:US
Mailing Address - Phone:518-262-6455
Mailing Address - Fax:
Practice Address - Street 1:43 NEW SCOTLAND AVENUE
Practice Address - Street 2:DEPT. OF EMERGENCY MEDICINE
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208
Practice Address - Country:US
Practice Address - Phone:518-262-6455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
64684390200000X
NY326136207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program