Provider Demographics
NPI:1295801835
Name:SPENCE, KIMBALL JOHN (DO)
Entity type:Individual
Prefix:
First Name:KIMBALL
Middle Name:JOHN
Last Name:SPENCE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 HWY 133
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:CO
Mailing Address - Zip Code:81623-1933
Mailing Address - Country:US
Mailing Address - Phone:970-963-3350
Mailing Address - Fax:970-963-2958
Practice Address - Street 1:1340 HWY 133
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:CO
Practice Address - Zip Code:81623-1933
Practice Address - Country:US
Practice Address - Phone:970-963-3350
Practice Address - Fax:970-963-2958
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31471207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01314715Medicaid
BS2347929OtherDEA
BS2347929OtherDEA
83444Medicare ID - Type Unspecified