Provider Demographics
NPI:1700851193
Name:SPENCER, CHARLA C (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLA
Middle Name:C
Last Name:SPENCER
Suffix:
Gender:F
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 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:1720 S BECKHAM AVE STE 104
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-4464
Practice Address - Country:US
Practice Address - Phone:903-597-2002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0615207VG0400X, 207VX0000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX039151802Medicaid
TX752616977026OtherTRICARE
TX75-2616977-136OtherTRICARE
TX8A0740OtherBCBS OF TEXAS
TX7600108OtherAETNA
TX8FL328OtherBCBS
TX039151801Medicaid
TX039151804Medicaid
TXP01572867OtherRAIL ROAD MEDICARE
TX123894OtherSUPERIOR CHIPS
TX039151805Medicaid
TX45-2578435-002OtherTRICARE
TX039151802Medicaid
TX039151801Medicaid
TX039151805Medicaid
TX8FL328OtherBCBS
TX75-2616977-136OtherTRICARE