Provider Demographics
NPI:1831629146
Name:SPRUNGER, MADISON A (OD)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:A
Last Name:SPRUNGER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-0549
Mailing Address - Country:US
Mailing Address - Phone:260-569-9550
Mailing Address - Fax:260-569-0760
Practice Address - Street 1:3510 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953
Practice Address - Country:US
Practice Address - Phone:765-662-6594
Practice Address - Fax:765-662-6595
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004037152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300004258Medicaid