Provider Demographics
NPI:1457312795
Name:SPENCER, DALE R
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:R
Last Name:SPENCER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-3408
Mailing Address - Country:US
Mailing Address - Phone:707-462-2602
Mailing Address - Fax:
Practice Address - Street 1:704 N STATE ST
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-3408
Practice Address - Country:US
Practice Address - Phone:707-462-2602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5466T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0054660Medicaid
CATI0000Medicare UPIN
CASD0054660Medicaid