Healthcare Provider Details

I. General information

NPI: 1942564315
Provider Name (Legal Business Name): SPENCER DANIEL RICHARDSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2012
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 RATLIFF ST
LUCEDALE MS
39452-5731
US

IV. Provider business mailing address

105 DRINKWATER BLVD DEPARTMENT OF SURGERY
BAY ST LOUIS MS
39520
US

V. Phone/Fax

Practice location:
  • Phone: 601-766-0308
  • Fax:
Mailing address:
  • Phone: 228-467-5983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number24758
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: