Provider Demographics
NPI:1407820491
Name:LAND, SPENCER (MD)
Entity Type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:
Last Name:LAND
Suffix:
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 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-450-6063
Mailing Address - Fax:904-539-4091
Practice Address - Street 1:1549 AIRPORT BLVD STE 200F
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8634
Practice Address - Country:US
Practice Address - Phone:850-416-1950
Practice Address - Fax:850-416-1951
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME116969208800000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36104761Medicaid
1671449OtherBCBS
IL21609137OtherBC/BS
ILL98021OtherMEDICARE
IL201995Medicare ID - Type Unspecified
212515003Medicare PIN
212216002Medicare PIN
ILL98021OtherMEDICARE
G51292Medicare UPIN
IL36104761Medicaid