Provider Demographics
NPI:1700049392
Name:SPENCER, JEFFREY WADE (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:WADE
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:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:1235 E CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2203
Practice Address - Country:US
Practice Address - Phone:417-820-2115
Practice Address - Fax:417-820-5344
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008015955207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1700049392Medicaid
MO500410043Medicare PIN