Provider Demographics
NPI:1619905684
Name:SPICER, MARK ANTHONY (PHD, MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:SPICER
Suffix:
Gender:M
Credentials:PHD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7270
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92552-7270
Mailing Address - Country:US
Mailing Address - Phone:951-656-1500
Mailing Address - Fax:951-656-1510
Practice Address - Street 1:28078 BAXTER ROAD
Practice Address - Street 2:SUITE 430
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-1404
Practice Address - Country:US
Practice Address - Phone:951-290-4378
Practice Address - Fax:951-290-4095
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA68609207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A686090Medicaid
CA00A686090Medicaid
CAWA68609AMedicare ID - Type Unspecified