Provider Demographics
NPI:1396374088
Name:HART, SPENCER ELDON (MD (MAY 15, 2020))
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:ELDON
Last Name:HART
Suffix:
Gender:M
Credentials:MD (MAY 15, 2020)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18TH MEDICAL GROUP
Mailing Address - Street 2:UNIT 5142
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96368-5142
Mailing Address - Country:US
Mailing Address - Phone:315-630-4817
Mailing Address - Fax:
Practice Address - Street 1:18TH MEDICAL GROUP
Practice Address - Street 2:UNIT 5142
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96368-5142
Practice Address - Country:US
Practice Address - Phone:315-630-4817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-03
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE34296208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE34296OtherSTATE MEDICAL BOARD