Provider Demographics
NPI:1487797122
Name:SPRAGUE, TIMOTHY JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JOSEPH
Last Name:SPRAGUE
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 1:2402 LA MESA DR
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90402-2343
Mailing Address - Country:US
Mailing Address - Phone:310-393-8895
Mailing Address - Fax:
Practice Address - Street 1:15031 RINALDI ST
Practice Address - Street 2:
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-1207
Practice Address - Country:US
Practice Address - Phone:818-898-4530
Practice Address - Fax:818-898-4451
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG371812085B0100X, 2085N0904X, 2085R0202X, 2085R0204X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA91871Medicare UPIN