Provider Demographics
NPI:1649239179
Name:SPRAGUE, WILLIAM ROBERT (OD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:ROBERT
Last Name:SPRAGUE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16126 81ST AV
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-8883
Mailing Address - Country:US
Mailing Address - Phone:715-726-9510
Mailing Address - Fax:715-669-5353
Practice Address - Street 1:102 E STANLEY ST
Practice Address - Street 2:
Practice Address - City:THORP
Practice Address - State:WI
Practice Address - Zip Code:54771
Practice Address - Country:US
Practice Address - Phone:715-669-5631
Practice Address - Fax:715-669-5353
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1359152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38568900Medicaid
87631Medicare ID - Type Unspecified
WI0411330001Medicare NSC
T63393Medicare UPIN
WI38568900Medicaid