Provider Demographics
NPI:1255675690
Name:FORWARD, SPENCER DAVID (IDC)
Entity Type:Individual
Prefix:MR
First Name:SPENCER
Middle Name:DAVID
Last Name:FORWARD
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6542 REFLECTION DR
Mailing Address - Street 2:APT# 1239
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-5120
Mailing Address - Country:US
Mailing Address - Phone:619-861-7073
Mailing Address - Fax:
Practice Address - Street 1:6542 REFLECTION DR
Practice Address - Street 2:APT# 1239
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92124-5120
Practice Address - Country:US
Practice Address - Phone:619-861-7073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman