Provider Demographics
NPI:1174264881
Name:WOLVERTON, SPENCER (DPM)
Entity Type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:
Last Name:WOLVERTON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 TULLAGEE AVE
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-6083
Mailing Address - Country:US
Mailing Address - Phone:208-206-5058
Mailing Address - Fax:
Practice Address - Street 1:330 MOUNT AUBURN ST.
Practice Address - Street 2:SOUTH 2-DEPARTMENT OF SURGERY
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-5502
Practice Address - Country:US
Practice Address - Phone:617-497-2420
Practice Address - Fax:617-499-5593
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA211D00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No211D00000XPodiatric Medicine & Surgery Service ProvidersAssistant, Podiatric