Healthcare Provider Details

I. General information

NPI: 1144279449
Provider Name (Legal Business Name): SPENCER FALCON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2006
Last Update Date: 04/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 WASHINGTON ST
WATERTOWN NY
13601-9367
US

IV. Provider business mailing address

1575 WASHINGTON ST
WATERTOWN NY
13601-9367
US

V. Phone/Fax

Practice location:
  • Phone: 315-779-5060
  • Fax: 315-779-5028
Mailing address:
  • Phone: 315-779-5060
  • Fax: 315-779-5028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number235367
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: