Healthcare Provider Details

I. General information

NPI: 1780761320
Provider Name (Legal Business Name): WAYNE ELLSWORTH SPRUCE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6160 MISSION GORGE RD SUITE 400
SAN DIEGO CA
92120-3410
US

IV. Provider business mailing address

2870 DOVE TAIL DR
SAN MARCOS CA
92078-0933
US

V. Phone/Fax

Practice location:
  • Phone: 619-528-4010
  • Fax: 619-528-4077
Mailing address:
  • Phone: 760-290-3678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberA24022
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: