Provider Demographics
NPI:1043281728
Name:SPENCER, GARY R (DC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:R
Last Name:SPENCER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 538
Mailing Address - Street 2:COLTS NECK SHOP CTR
Mailing Address - City:COLTS NECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07722-0538
Mailing Address - Country:US
Mailing Address - Phone:732-462-0049
Mailing Address - Fax:732-462-0059
Practice Address - Street 1:30 HIGHWAY 34 N
Practice Address - Street 2:
Practice Address - City:COLTS NECK
Practice Address - State:NJ
Practice Address - Zip Code:07722-0538
Practice Address - Country:US
Practice Address - Phone:732-462-0049
Practice Address - Fax:732-462-0059
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMC0181900111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ072818Medicare PIN