Healthcare Provider Details

I. General information

NPI: 1124513023
Provider Name (Legal Business Name): SPENCER FULLER MD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2018
Last Update Date: 08/16/2024
Certification Date: 08/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5449 RENO CORPORATE DR STE 200
RENO NV
89511-2626
US

IV. Provider business mailing address

5449 RENO CORPORATE DR STE 200
RENO NV
89511-2626
US

V. Phone/Fax

Practice location:
  • Phone: 775-737-9411
  • Fax: 775-737-9413
Mailing address:
  • Phone: 775-737-9411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number2018020280
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number12685949-1205
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number24889
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2018020280
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: