Provider Demographics
NPI:1609803691
Name:SPENCER, DONAVAN D (MD)
Entity Type:Individual
Prefix:MR
First Name:DONAVAN
Middle Name:D
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 1:205 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-5540
Mailing Address - Country:US
Mailing Address - Phone:707-964-1251
Mailing Address - Fax:
Practice Address - Street 1:205 SOUTH ST
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-5540
Practice Address - Country:US
Practice Address - Phone:707-964-1251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD26431208000000X
CAG85455208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G854550OtherBS OF CA
CA00G854550Medicaid
G28103Medicare UPIN
CA00G854551Medicare ID - Type Unspecified