Healthcare Provider Details

I. General information

NPI: 1861494304
Provider Name (Legal Business Name): PATRICK L SPENCER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 W GRAND AVE STE 1002
DAYTON OH
45405-4775
US

IV. Provider business mailing address

425 W GRAND AVE STE 1002
DAYTON OH
45405-4775
US

V. Phone/Fax

Practice location:
  • Phone: 937-298-5536
  • Fax: 937-298-5596
Mailing address:
  • Phone: 937-226-7870
  • Fax: 937-226-7829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number34-00-6232-S
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: