Provider Demographics
NPI:1205828647
Name:SPENCER, JAMES BERTHOLD (MD)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:BERTHOLD
Last Name:SPENCER
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 1:139 W. LAMAR
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:TX
Mailing Address - Zip Code:75951-4014
Mailing Address - Country:US
Mailing Address - Phone:409-384-6829
Mailing Address - Fax:409-384-7861
Practice Address - Street 1:139 W. LAMAR
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TX
Practice Address - Zip Code:75951-4014
Practice Address - Country:US
Practice Address - Phone:409-384-6229
Practice Address - Fax:409-384-7861
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD4315146D00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC22115Medicare UPIN