Provider Demographics
NPI:1447962766
Name:MARTIN, SPENCER DALTON (IDC)
Entity type:Individual
Prefix:MR
First Name:SPENCER
Middle Name:DALTON
Last Name:MARTIN
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FARENHOLT AVE BLDG 14
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-0001
Mailing Address - Country:US
Mailing Address - Phone:619-532-7968
Mailing Address - Fax:
Practice Address - Street 1:213 WESTFIELD DR
Practice Address - Street 2:
Practice Address - City:RICHLANDS
Practice Address - State:NC
Practice Address - Zip Code:28574-8009
Practice Address - Country:US
Practice Address - Phone:850-200-2251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-19
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program