Provider Demographics
NPI:1841298429
Name:SPROED, JOHN D I (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:D
Last Name:SPROED
Suffix:I
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 1:2156 FISHER RD
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-9216
Mailing Address - Country:US
Mailing Address - Phone:541-673-4513
Mailing Address - Fax:541-673-3116
Practice Address - Street 1:868 NW GARDEN VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-1959
Practice Address - Country:US
Practice Address - Phone:541-492-5433
Practice Address - Fax:541-672-6384
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2007-07-08
Deactivation Date:2006-03-15
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
ORMD6562174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR182626Medicaid
OR182626Medicaid
ORC93827Medicare UPIN