Provider Demographics
NPI:1245326081
Name:SPROWL, DAVID W (PT, MSBA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:W
Last Name:SPROWL
Suffix:
Gender:M
Credentials:PT, MSBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 N CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-5886
Mailing Address - Country:US
Mailing Address - Phone:260-484-8551
Mailing Address - Fax:260-484-9603
Practice Address - Street 1:5050 N CLINTON ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5886
Practice Address - Country:US
Practice Address - Phone:260-484-8551
Practice Address - Fax:260-484-9603
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05000652A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100357800Medicaid
IN000000173915OtherANTHEM
156562Medicare ID - Type Unspecified
IN058940VVVVMedicare PIN