Provider Demographics
NPI: | 1093009748 |
---|---|
Name: | SPENCER, VICTORIA OLUWASEUN (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | VICTORIA |
Middle Name: | OLUWASEUN |
Last Name: | SPENCER |
Suffix: | |
Gender: | F |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | VICTORIA |
Other - Middle Name: | SEUN |
Other - Last Name: | DEBOISE |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | MD |
Mailing Address - Street 1: | PO BOX 22000 |
Mailing Address - Street 2: | |
Mailing Address - City: | SAN ANGELO |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 76902-7200 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 325-658-1511 |
Mailing Address - Fax: | 325-481-2166 |
Practice Address - Street 1: | 4500 MEMORIAL DR |
Practice Address - Street 2: | |
Practice Address - City: | BELLEVILLE |
Practice Address - State: | IL |
Practice Address - Zip Code: | 62226-5360 |
Practice Address - Country: | US |
Practice Address - Phone: | 618-257-6220 |
Practice Address - Fax: | 618-257-6679 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2011-05-30 |
Last Update Date: | 2023-05-31 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | Q8646 | 207Q00000X |
IL | 036147766 | 208M00000X |
IN | 01086884A | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | |
No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | Q8646 | Other | TEXAS LICENSE |