Healthcare Provider Details

I. General information

NPI: 1366963381
Provider Name (Legal Business Name): SPENCER RICHARD AUGUSTIN DO, FAACAP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2017
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 C ST STE 606
ANCHORAGE AK
99503-3971
US

IV. Provider business mailing address

PO BOX 241889
ANCHORAGE AK
99524-1889
US

V. Phone/Fax

Practice location:
  • Phone: 907-258-7575
  • Fax: 907-561-7464
Mailing address:
  • Phone: 907-563-1777
  • Fax: 907-561-7464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number185478
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number185478
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1730692
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: