Healthcare Provider Details

I. General information

NPI: 1306956453
Provider Name (Legal Business Name): LEWIS W SPRUNGER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 NW EASTMAN PKWY 100
GRESHAM OR
97030-3858
US

IV. Provider business mailing address

1550 NW EASTMAN PKWY SUITE 100
GRESHAM OR
97030-3858
US

V. Phone/Fax

Practice location:
  • Phone: 503-571-0725
  • Fax: 503-571-0720
Mailing address:
  • Phone: 503-571-0725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD13478
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD00035731
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: