Provider Demographics
NPI:1255314837
Name:SPRUNG, ROBERT F JR (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:F
Last Name:SPRUNG
Suffix:JR
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:PO BOX 2769
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87499-4559
Mailing Address - Country:US
Mailing Address - Phone:505-326-3697
Mailing Address - Fax:505-327-9688
Practice Address - Street 1:2700 FARMINGTON AVE.
Practice Address - Street 2:BUILDING I, SUITE 2
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-1202
Practice Address - Country:US
Practice Address - Phone:505-326-3691
Practice Address - Fax:505-327-9688
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-28
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2008-0311174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM37782738Medicaid
NM37782738Medicaid