Provider Demographics
NPI:1376548230
Name:SPENCER, STEPHEN E SR (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:E
Last Name:SPENCER
Suffix:SR
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 1:6565 W EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8737
Mailing Address - Country:US
Mailing Address - Phone:208-377-5055
Mailing Address - Fax:208-377-5335
Practice Address - Street 1:6565 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8737
Practice Address - Country:US
Practice Address - Phone:208-377-5055
Practice Address - Fax:208-377-5335
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3666207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002762400Medicaid
ID002762400Medicaid
IDC36849Medicare UPIN