Provider Demographics
NPI:1053842914
Name:BLACK, SPENCER EVAN (MD)
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:EVAN
Last Name:BLACK
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 1:295 S CHIPETA WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1287
Mailing Address - Country:US
Mailing Address - Phone:859-313-7711
Mailing Address - Fax:
Practice Address - Street 1:2250 N MILLER CAMPUS DR
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-7233
Practice Address - Country:US
Practice Address - Phone:859-313-7711
Practice Address - Fax:385-531-1805
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-22
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12759564-1205208000000X, 2084P0800X, 2084P0800X
UT12759564-89052084P0804X
KY55619208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty