Healthcare Provider Details

I. General information

NPI: 1477643799
Provider Name (Legal Business Name): ILENE M. SPECTOR D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2006
Last Update Date: 01/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

277A BLACKSTOCK DR.
CRESTED BUTTE CO
81224
US

IV. Provider business mailing address

277A BLACKSTOCK DR.
CRESTED BUTTE CO
81224
US

V. Phone/Fax

Practice location:
  • Phone: 970-349-2095
  • Fax: 970-349-2095
Mailing address:
  • Phone: 970-349-2095
  • Fax: 970-349-2095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number41577
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number2588
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number41577
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number2588
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: