Provider Demographics
NPI:1649283623
Name:SPRAGUE, RANDY S (MD)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:S
Last Name:SPRAGUE
Suffix:
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 1:3691 RUTGER ST
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2515
Mailing Address - Country:US
Mailing Address - Phone:314-977-6828
Mailing Address - Fax:314-977-6777
Practice Address - Street 1:3660 VISTA AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2540
Practice Address - Country:US
Practice Address - Phone:314-577-6095
Practice Address - Fax:314-577-6121
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7946207R00000X, 208U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered208U00000XAllopathic & Osteopathic PhysiciansClinical Pharmacology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA12447Medicare UPIN
MO07410247Medicare ID - Type Unspecified