Provider Demographics
NPI:1205194693
Name:IDSTEIN, SPENCER RYAN (MD)
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:RYAN
Last Name:IDSTEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6341 MEETING ST STE 102
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-8731
Mailing Address - Country:US
Mailing Address - Phone:502-566-0300
Mailing Address - Fax:
Practice Address - Street 1:6341 MEETING ST STE 102
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:KY
Practice Address - Zip Code:40059-8731
Practice Address - Country:US
Practice Address - Phone:502-566-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-24
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY49531208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100439060Medicaid
KYK205110Medicare PIN