Healthcare Provider Details

I. General information

NPI: 1033451950
Provider Name (Legal Business Name): KENRICK ANTHONY SPENCE I M.D., F.A.C.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2013
Last Update Date: 09/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 HILLCREST ST
ORLANDO FL
32801-1210
US

IV. Provider business mailing address

130 HILLCREST ST
ORLANDO FL
32801-1210
US

V. Phone/Fax

Practice location:
  • Phone: 407-999-2585
  • Fax: 407-999-2628
Mailing address:
  • Phone: 407-999-2585
  • Fax: 407-999-2628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberME77827
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: