Healthcare Provider Details

I. General information

NPI: 1144437518
Provider Name (Legal Business Name): ARIEL SPENCER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 10/12/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 N TOWNLINE RD STE 101
LAGRANGE IN
46761-1325
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 260-463-9316
  • Fax: 260-463-9334
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD 47599
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number01066930A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: