Provider Demographics
NPI:1629161823
Name:ROBERT G. SPENCER MD PLLC
Entity Type:Organization
Organization Name:ROBERT G. SPENCER MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-623-2233
Mailing Address - Street 1:PO BOX 60
Mailing Address - Street 2:
Mailing Address - City:WATONGA
Mailing Address - State:OK
Mailing Address - Zip Code:73772-0060
Mailing Address - Country:US
Mailing Address - Phone:580-623-2233
Mailing Address - Fax:580-623-2232
Practice Address - Street 1:203 N WEIGLE AVE
Practice Address - Street 2:
Practice Address - City:WATONGA
Practice Address - State:OK
Practice Address - Zip Code:73772-3840
Practice Address - Country:US
Practice Address - Phone:580-623-2233
Practice Address - Fax:580-623-2232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2011-12-20
Deactivation Date:2008-07-25
Deactivation Code:
Reactivation Date:2010-10-28
Provider Licenses
StateLicense IDTaxonomies
OK23186207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200007580DMedicaid
OKI38111Medicare UPIN
OK200007580DMedicaid