Provider Demographics
NPI:1922591114
Name:CARTER, SPENCER VAUGHN (MD)
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:VAUGHN
Last Name:CARTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SPENCER
Other - Middle Name:VAUGHN
Other - Last Name:CARTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:180 HARVESTER DR STE 110
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-6686
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-1443
Practice Address - Country:US
Practice Address - Phone:214-648-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.072017207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine