Provider Demographics
NPI:1548355902
Name:SPENCER, EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
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 1:502 WEST JASPER
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-1312
Mailing Address - Country:US
Mailing Address - Phone:254-526-6300
Mailing Address - Fax:254-526-6349
Practice Address - Street 1:502 WEST JASPER
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-1312
Practice Address - Country:US
Practice Address - Phone:254-526-6300
Practice Address - Fax:254-526-6349
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0837173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F5210Medicare PIN
TXE02247Medicare UPIN