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NPI Code Detail

MEDICARE: DR. ISAAC SAMUEL SPARKS D.O.

MEDICARE: DR. ISAAC SAMUEL SPARKS D.O.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician9695910-1204UT
2207Q00000XFamily Medicine Physician2024-01122NC

General Provider Information

NPI Number : 1205276086
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. ISAAC SAMUEL SPARKS D.O.
Provider Business Mailing Address
First Line : PO BOX 27128
Second Line :
City : SALT LAKE CITY
State : UT
Zip : 84127-0128
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 301 E WENDOVER AVE STE 215
Second Line :
City : GREENSBORO
State : NC
Zip : 27401-1207
Country : US
Telephone Number : 336-379-1156
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/26/2013
Last Update Date : 06/19/2024

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