Provider Demographics
NPI:1114564135
Name:FANG, SPENCER (PT, DPT)
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:
Last Name:FANG
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1824 JOHNS DR
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-1657
Mailing Address - Country:US
Mailing Address - Phone:847-581-6300
Mailing Address - Fax:
Practice Address - Street 1:1824 JOHNS DR
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-1657
Practice Address - Country:US
Practice Address - Phone:847-581-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-09
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070024872208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation