Provider Demographics
NPI:1497794796
Name:SPENCE, JOHN A (M D)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:SPENCE
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4284 KELSON AVENUE
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446
Mailing Address - Country:US
Mailing Address - Phone:850-482-2910
Mailing Address - Fax:850-482-2836
Practice Address - Street 1:4284 KELSON AVE
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-2948
Practice Address - Country:US
Practice Address - Phone:850-482-2910
Practice Address - Fax:850-482-2836
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL84174207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00025788OtherMEDICARE RAILROAD
FL13614OtherBLUECROSS BLUESHIELD FLORIDA
FL264600500Medicaid
FLE8248ZOtherMEDICARE PTAN
FL13614OtherBLUECROSS BLUESHIELD FLORIDA
FL264600500Medicaid