Healthcare Provider Details

I. General information

NPI: 1922065689
Provider Name (Legal Business Name): MICHAEL ANTONIO SPENCER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 01/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 GREEN VALLEY RD KOALA EYE CENTRE STE 303
GREENSBORO NC
27408-7014
US

IV. Provider business mailing address

719 GREEN VALLEY RD KOALA EYE CENTRE STE 303
GREENSBORO NC
27408-7014
US

V. Phone/Fax

Practice location:
  • Phone: 336-378-2511
  • Fax: 336-378-1186
Mailing address:
  • Phone: 336-378-2511
  • Fax: 336-378-1186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0110X
TaxonomyPediatric Ophthalmology and Strabismus Specialist Physician Physician
License Number200100470
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number200100470
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: