Provider Demographics
NPI:1992888705
Name:SPENCER, DAVID A (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:SPENCER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 8TH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-7301
Mailing Address - Country:US
Mailing Address - Phone:208-746-1383
Mailing Address - Fax:208-298-4520
Practice Address - Street 1:2315 8TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-7301
Practice Address - Country:US
Practice Address - Phone:208-746-1383
Practice Address - Fax:208-298-4520
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM2959208600000X
WAMD00012565208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010006002OtherREGENCE BLUESHIELD
WA1578509Medicaid
IDDF516OtherBLUE CROSS
ID002385800Medicaid
ID002385800OtherHEALTHY CONNECTIONS
WA31261OtherWA LABOR & INDUSTRIES
ID000010006002OtherREGENCE BLUESHIELD
IDD73442Medicare UPIN
ID1107921Medicare PIN
ID002385800Medicaid