Provider Demographics
NPI:1538124292
Name:SPENCER, TERRENCE S (MD)
Entity Type:Individual
Prefix:DR
First Name:TERRENCE
Middle Name:S
Last Name:SPENCER
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 1:1901 W PARKWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-2092
Mailing Address - Country:US
Mailing Address - Phone:018-862-0208
Mailing Address - Fax:012-728-8678
Practice Address - Street 1:4878 S HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-6007
Practice Address - Country:US
Practice Address - Phone:801-214-0304
Practice Address - Fax:012-728-8678
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV19792207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1538124292Medicaid
COC801892Medicare PIN
COI29584Medicare UPIN