Provider Demographics
NPI:1447278940
Name:SPRUNG, LARRY (MD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:
Last Name:SPRUNG
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 1:5900 N PORT WASHINGTON RD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217
Mailing Address - Country:US
Mailing Address - Phone:414-962-4048
Mailing Address - Fax:414-962-4052
Practice Address - Street 1:5900 N PORT WASHINGTON RD
Practice Address - Street 2:SUITE 230
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217
Practice Address - Country:US
Practice Address - Phone:414-962-4048
Practice Address - Fax:414-962-4052
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI285950202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31610100Medicaid
E72253Medicare UPIN