1295296812 NPI number — COREY SPENCE DO

Table of content: COREY SPENCE DO (NPI 1295296812)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295296812 NPI number — COREY SPENCE DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPENCE
Provider First Name:
COREY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295296812
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1111 W. 17TH ST., BARSON 241
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74107-1898
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-561-8432
Provider Business Mailing Address Fax Number:
918-561-8428

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1425 GREENWAY DR STE 360
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IRVING
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75038-2447
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
844-824-8775
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/27/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: U1773 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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