Healthcare Provider Details

I. General information

NPI: 1831583426
Provider Name (Legal Business Name): ROBERT SPENCER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2015
Last Update Date: 07/12/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2460 HYLAN BLVD
STATEN ISLAND NY
10306-3117
US

IV. Provider business mailing address

197 VAN VORST ST APT 305
JERSEY CITY NJ
07302-4754
US

V. Phone/Fax

Practice location:
  • Phone: 718-226-5619
  • Fax:
Mailing address:
  • Phone: 646-334-8057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number286003
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: