Provider Demographics
NPI:1316905888
Name:SPRAGUE, TERRY L (DO)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:L
Last Name:SPRAGUE
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 1:222 BROADWAY
Mailing Address - Street 2:AUDUBON MEDICAL CLINIC
Mailing Address - City:AUDUBON
Mailing Address - State:IA
Mailing Address - Zip Code:50025
Mailing Address - Country:US
Mailing Address - Phone:712-563-4206
Mailing Address - Fax:712-563-2001
Practice Address - Street 1:222 BROADWAY
Practice Address - Street 2:AUDUBON MEDICAL CLINIC
Practice Address - City:AUDUBON
Practice Address - State:IA
Practice Address - Zip Code:50025
Practice Address - Country:US
Practice Address - Phone:712-563-4206
Practice Address - Fax:712-563-2001
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA01713207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0152082OtherMEDICAID HOSPITAL
IA15208OtherWELLMARK
IAI3937OtherMEDICARE B
IA0638536Medicaid
IA163853Medicare PIN
A01336Medicare UPIN