Provider Demographics
NPI:1073573788
Name:SPENCE, TIMOTHY GLENN (OD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:GLENN
Last Name:SPENCE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4330 JOHNS CREEK PKWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6120
Mailing Address - Country:US
Mailing Address - Phone:770-232-7844
Mailing Address - Fax:770-232-9455
Practice Address - Street 1:9550 JONES BRIDGE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022
Practice Address - Country:US
Practice Address - Phone:770-475-1242
Practice Address - Fax:770-475-1032
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001255152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4578OtherMEDICARE GROUP
GA1912195272OtherGROUP NPI
GA000493347BMedicaid
GAU20046Medicare UPIN
GA000493347BMedicaid