Provider Demographics
NPI:1134285539
Name:SPENCER, MARK A (DN)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:SPENCER
Suffix:
Gender:M
Credentials:DN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15850 NEW AVE
Mailing Address - Street 2:
Mailing Address - City:LEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60439-3680
Mailing Address - Country:US
Mailing Address - Phone:815-302-2784
Mailing Address - Fax:630-243-8807
Practice Address - Street 1:15850 NEW AVE
Practice Address - Street 2:
Practice Address - City:LEMONT
Practice Address - State:IL
Practice Address - Zip Code:60439-3680
Practice Address - Country:US
Practice Address - Phone:815-302-2784
Practice Address - Fax:630-243-8807
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02232712OtherBLUE CROSS BLUE SHIELD IL