Provider Demographics
NPI:1750398467
Name:SPENCER, DAVID KEITH (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:KEITH
Last Name:SPENCER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:IL
Mailing Address - Zip Code:62812-1017
Mailing Address - Country:US
Mailing Address - Phone:618-439-7256
Mailing Address - Fax:618-439-7257
Practice Address - Street 1:711 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:IL
Practice Address - Zip Code:62812-1017
Practice Address - Country:US
Practice Address - Phone:618-439-7256
Practice Address - Fax:618-439-7257
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007635152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046007635Medicaid
IL046007635Medicaid
U25863Medicare UPIN
720780Medicare ID - Type Unspecified