Healthcare Provider Details

I. General information

NPI: 1659877884
Provider Name (Legal Business Name): SPENCER ALEXANDER DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2018
Last Update Date: 10/27/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S 20TH ST STE B
ROGERS AR
72758-1100
US

IV. Provider business mailing address

200 S 20TH ST STE B
ROGERS AR
72758-1100
US

V. Phone/Fax

Practice location:
  • Phone: 479-636-9393
  • Fax: 479-636-9341
Mailing address:
  • Phone: 479-636-9393
  • Fax: 479-636-9341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number305
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: