Provider Demographics
NPI:1548465834
Name:SPENCER, JARED R (MD)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:R
Last Name:SPENCER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6823 ISAAC'S ORCHARD RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762
Mailing Address - Country:US
Mailing Address - Phone:479-750-2080
Mailing Address - Fax:479-750-2082
Practice Address - Street 1:6823 ISAAC'S ORCHARD RD
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762
Practice Address - Country:US
Practice Address - Phone:479-750-2080
Practice Address - Fax:479-750-2082
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA95600207YS0123X
AZ37260207YS0123X
ARE6045207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR179309001Medicaid
AR179309001Medicaid
AR5H535Medicare PIN