=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831176858
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL STEWART SPICER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2005
-----------------------------------------------------
Last Update Date | 12/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7960 N WICKHAM RD STE 103
-----------------------------------------------------
City | VIERA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32940-8096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-428-4737
-----------------------------------------------------
Fax | 321-567-7542
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8057 SPYGLASS HILL RD
-----------------------------------------------------
City | VIERA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32940-8565
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-428-4737
-----------------------------------------------------
Fax | 321-567-7542
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | ME82521
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------