Provider Demographics
NPI:1922359702
Name:SOUTHERLAND, SPENCER COREY (IDC)
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:COREY
Last Name:SOUTHERLAND
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SEAL TEAM 2
Mailing Address - Street 2:UNIT 60003
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09501-4633
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:SEAL TEAM 2
Practice Address - Street 2:UNIT 60003
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09501-4633
Practice Address - Country:US
Practice Address - Phone:360-286-0972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-20
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider