Provider Demographics
NPI:1215124276
Name:SPARKS CLINIC P.C.
Entity type:Organization
Organization Name:SPARKS CLINIC P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:SPARKS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:660-665-1400
Mailing Address - Street 1:1410 CROWN DR
Mailing Address - Street 2:PO BOX 703
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-2548
Mailing Address - Country:US
Mailing Address - Phone:660-665-1400
Mailing Address - Fax:660-665-2081
Practice Address - Street 1:1410 CROWN DR
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-2548
Practice Address - Country:US
Practice Address - Phone:660-665-1400
Practice Address - Fax:660-665-2081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5954207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MODG0675OtherPALMETTO GBA
D 41749Medicare UPIN