Provider Demographics
NPI:1891466561
Name:DONG, SPENCER
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:
Last Name:DONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10580 S DE ANZA BLVD
Mailing Address - Street 2:
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-4450
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10580 S DE ANZA BLVD
Practice Address - Street 2:
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-4450
Practice Address - Country:US
Practice Address - Phone:408-366-1735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300793225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist