Provider Demographics
NPI:1750430104
Name:SPENCER, FREDERICK R (DPM)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:R
Last Name:SPENCER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1432 CALCUTTA LN
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-2215
Mailing Address - Country:US
Mailing Address - Phone:708-246-4591
Mailing Address - Fax:708-246-2086
Practice Address - Street 1:608 HILLGROVE AVE
Practice Address - Street 2:
Practice Address - City:WESTERN SPRINGS
Practice Address - State:IL
Practice Address - Zip Code:60558-1476
Practice Address - Country:US
Practice Address - Phone:708-246-4591
Practice Address - Fax:708-246-2086
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2008-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-003528213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016003528Medicaid
ILT37836Medicare UPIN
IL724810Medicare PIN