Basic Information
| Provider Information | |||||||||
| NPI: | 1629055678 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARLSTONE | ||||||||
| FirstName: | SPENCER | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 405 MONROE ST | ||||||||
| Address2: | |||||||||
| City: | PELLA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502191189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6416212200 | ||||||||
| FaxNumber: | 6416212335 | ||||||||
| Practice Location | |||||||||
| Address1: | 405 MONROE ST | ||||||||
| Address2: | |||||||||
| City: | PELLA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502191189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6416212200 | ||||||||
| FaxNumber: | 6416212335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2005 | ||||||||
| LastUpdateDate: | 08/30/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | M0031 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | E4698 | AR | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 36471 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0490896 | 05 | IA | MEDICAID | 1490896 | 05 | IA | MEDICAID | 171434701 | 05 | TX | MEDICAID | 4490896 | 05 | IA | MEDICAID | 2490896 | 05 | IA | MEDICAID | 3490896 | 05 | IA | MEDICAID |