Healthcare Provider Details

I. General information

NPI: 1235750670
Provider Name (Legal Business Name): SPENCER MOORE MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2020
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15401 N 29TH AVE
PHOENIX AZ
85053-4000
US

IV. Provider business mailing address

15401 N 29TH AVE
PHOENIX AZ
85053-4000
US

V. Phone/Fax

Practice location:
  • Phone: 602-682-2770
  • Fax:
Mailing address:
  • Phone: 602-682-2770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberV0816
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberR78055
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number78178
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberR78055
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: