Basic Information
| Provider Information | |||||||||
| NPI: | 1174264881 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOLVERTON | ||||||||
| FirstName: | SPENCER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1508 TULLAGEE AVE | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329406083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082065058 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 330 MOUNT AUBURN ST. | ||||||||
| Address2: | SOUTH 2-DEPARTMENT OF SURGERY | ||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021385502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174972420 | ||||||||
| FaxNumber: | 6174995593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2022 | ||||||||
| LastUpdateDate: | 04/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 211D00000X | MA | N | Podiatric Medicine & Surgery Service Providers | Assistant, Podiatric | 390200000X | MA | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.