Provider Demographics
NPI:1770568602
Name:SPENCER, RICHARD BRUCE (DPM)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:BRUCE
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 1:110 E MCLANE
Mailing Address - Street 2:
Mailing Address - City:OSCEOLA
Mailing Address - State:IA
Mailing Address - Zip Code:50213-1457
Mailing Address - Country:US
Mailing Address - Phone:641-342-6054
Mailing Address - Fax:641-342-2292
Practice Address - Street 1:110 E MCLANE
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:IA
Practice Address - Zip Code:50213-1457
Practice Address - Country:US
Practice Address - Phone:641-342-6054
Practice Address - Fax:641-342-2292
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00413213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA4214171Medicaid
IA00413OtherPODIATRY LICENSE
IA4214171Medicaid
IA55877Medicare ID - Type Unspecified