Provider Demographics
NPI:1376569699
Name:SPECTOR, GERSHON J (MD)
Entity Type:Individual
Prefix:DR
First Name:GERSHON
Middle Name:J
Last Name:SPECTOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:C B 8115
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-362-7509
Mailing Address - Fax:314-747-5593
Practice Address - Street 1:4921 PARKVIEW PL
Practice Address - Street 2:STE 11A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-362-7509
Practice Address - Fax:314-747-9744
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR4322207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO007010206Medicaid
IL0230164077Medicaid
MO007010206Medicare PIN
MO040008893Medicare PIN