Provider Demographics
NPI:1477643799
Name:SPECTOR, ILENE M (DO)
Entity Type:Individual
Prefix:DR
First Name:ILENE
Middle Name:M
Last Name:SPECTOR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:277A BLACKSTOCK DR.
Mailing Address - Street 2:
Mailing Address - City:CRESTED BUTTE
Mailing Address - State:CO
Mailing Address - Zip Code:81224
Mailing Address - Country:US
Mailing Address - Phone:970-349-2095
Mailing Address - Fax:970-349-2095
Practice Address - Street 1:277A BLACKSTOCK DR.
Practice Address - Street 2:
Practice Address - City:CRESTED BUTTE
Practice Address - State:CO
Practice Address - Zip Code:81224
Practice Address - Country:US
Practice Address - Phone:970-349-2095
Practice Address - Fax:970-349-2095
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-15
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO41577204D00000X, 208D00000X
AZ2588204D00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZE68579Medicare UPIN