Provider Demographics
NPI:1922065689
Name:SPENCER, MICHAEL ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTONIO
Last Name:SPENCER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:719 GREEN VALLEY RD
Mailing Address - Street 2:KOALA EYE CENTRE STE 303
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-7014
Mailing Address - Country:US
Mailing Address - Phone:336-378-2511
Mailing Address - Fax:336-378-1186
Practice Address - Street 1:719 GREEN VALLEY RD
Practice Address - Street 2:KOALA EYE CENTRE STE 303
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7014
Practice Address - Country:US
Practice Address - Phone:336-378-2511
Practice Address - Fax:336-378-1186
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2019-01-24
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Provider Licenses
StateLicense IDTaxonomies
NC200100470207WX0110X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0110XAllopathic & Osteopathic PhysiciansOphthalmologyPediatric Ophthalmology and Strabismus Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8913132Medicaid
NC010678177OtherTAX I.D.
NC2328003Medicare PIN