Provider Demographics
NPI:1790781292
Name:HENINGER, SPENCER BOWEN (DPM)
Entity Type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:BOWEN
Last Name:HENINGER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 N 400 E
Mailing Address - Street 2:STE A
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-1788
Mailing Address - Country:US
Mailing Address - Phone:435-787-2000
Mailing Address - Fax:435-787-1913
Practice Address - Street 1:2310 N 400 E
Practice Address - Street 2:STE A
Practice Address - City:NORTH LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1788
Practice Address - Country:US
Practice Address - Phone:435-787-2000
Practice Address - Fax:435-787-1913
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5336197-0501213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTV05693Medicare UPIN
UT5166950001Medicare NSC