Provider Demographics
NPI:1306838669
Name:SPENCER, JACQUELINE M (DO)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:M
Last Name:SPENCER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4567 CROSSROADS PARK DR.
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088
Mailing Address - Country:US
Mailing Address - Phone:315-295-2100
Mailing Address - Fax:315-295-2125
Practice Address - Street 1:1452 DEER PARK AVE
Practice Address - Street 2:
Practice Address - City:NORTH BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11703
Practice Address - Country:US
Practice Address - Phone:631-254-8500
Practice Address - Fax:631-254-8503
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY214310207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02109855Medicaid
22V031Medicare PIN
NY22V031Medicare ID - Type UnspecifiedINDIV #
NY02109855Medicaid
NYH25614Medicare UPIN