Healthcare Provider Details

I. General information

NPI: 1649283623
Provider Name (Legal Business Name): RANDY S. SPRAGUE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3660 VISTA AVE
SAINT LOUIS MO
63110-2540
US

IV. Provider business mailing address

3691 RUTGER ST PROVIDER ENROLLMENT
SAINT LOUIS MO
63110-2515
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-6095
  • Fax: 314-577-6121
Mailing address:
  • Phone: 314-977-6828
  • Fax: 314-977-6777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberR7946
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208U00000X
TaxonomyClinical Pharmacology Physician
License NumberR7946
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: