Provider Demographics
NPI:1124194295
Name:GARY C. SPENCER O.D., P.C.
Entity Type:Organization
Organization Name:GARY C. SPENCER O.D., P.C.
Other - Org Name:OPTOMETRY WEST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:C
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:734-369-4833
Mailing Address - Street 1:2624 OXFORD CIR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-2447
Mailing Address - Country:US
Mailing Address - Phone:734-369-4833
Mailing Address - Fax:
Practice Address - Street 1:2624 OXFORD CIR
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-2447
Practice Address - Country:US
Practice Address - Phone:734-369-4833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002683152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900F165210OtherBLUE CARE NETWORK
MI0F11250OtherBCBS
MI71020000F16521OtherBCBS
MI=========OtherTAX ID # CORPORATE
MI0N50770Medicare PIN
MI0F11250OtherBCBS
MI4686090001Medicare NSC
MI0N50770Medicare ID - Type Unspecified