MEDICARE: DR. JACQUELINE M SPENCER DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	214310	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306838669
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACQUELINE M SPENCER DO

Provider Business Mailing Address
First Line	:	4567 CROSSROADS PARK DR.
Second Line	:
City	:	LIVERPOOL
State	:	NY
Zip	:	13088
Country	:	US
Telephone Number	:	315-295-2100
Fax Number	:	315-295-2125

Provider Business Practice Location Address
First Line	:	1452 DEER PARK AVE
Second Line	:
City	:	NORTH BABYLON
State	:	NY
Zip	:	11703
Country	:	US
Telephone Number	:	631-254-8500
Fax Number	:	631-254-8503

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2005
Last Update Date	:	03/09/2009

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