Provider Demographics
NPI:1922099506
Name:SPORLEDER, PATRICK G (DO)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:G
Last Name:SPORLEDER
Suffix:
Gender:M
Credentials:DO
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 1027
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65102-1027
Mailing Address - Country:US
Mailing Address - Phone:573-681-3767
Mailing Address - Fax:573-761-6947
Practice Address - Street 1:3527 W TRUMAN BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-5715
Practice Address - Country:US
Practice Address - Phone:573-761-7979
Practice Address - Fax:573-761-5515
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4N43207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO243057858Medicaid
MO151900007Medicare PIN
MOE87123Medicare UPIN