Healthcare Provider Details

I. General information

NPI: 1508358631
Provider Name (Legal Business Name): SPENCER LOUIS BLUMBERG D.M.D., M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2018
Last Update Date: 01/20/2025
Certification Date: 01/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 NW 40TH TER STE C
GAINESVILLE FL
32605-5814
US

IV. Provider business mailing address

2121 NW 40TH TER STE C
GAINESVILLE FL
32605-5814
US

V. Phone/Fax

Practice location:
  • Phone: 352-378-2525
  • Fax: 352-392-7609
Mailing address:
  • Phone: 352-378-2525
  • Fax: 352-392-7609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN23373
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: