Provider Demographics
NPI:1376694281
Name:SPENCER, RANDALL BURL (MD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:BURL
Last Name:SPENCER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18583 DECATUR RD
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95030-3086
Mailing Address - Country:US
Mailing Address - Phone:408-354-0958
Mailing Address - Fax:
Practice Address - Street 1:90 GREAT OAKS BLVD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95119-1314
Practice Address - Country:US
Practice Address - Phone:408-281-0708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA232980207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA23467Medicare UPIN
CA00A232980Medicare PIN