Provider Demographics
NPI:1639165038
Name:GREENDYKE, SPENCER D (MD)
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:D
Last Name:GREENDYKE
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 1:3318 N GRAND MILL LN
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814
Mailing Address - Country:US
Mailing Address - Phone:208-277-1060
Mailing Address - Fax:208-277-1065
Practice Address - Street 1:3318 N GRAND MILL LN
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-5689
Practice Address - Country:US
Practice Address - Phone:208-277-1060
Practice Address - Fax:208-277-1065
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-21
Last Update Date:2012-02-23
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
IDM9110207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807145800Medicaid
IDG32071Medicare UPIN
ID807145800Medicaid