Healthcare Provider Details

I. General information

NPI: 1003275413
Provider Name (Legal Business Name): SPARCC PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2016
Last Update Date: 05/13/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5199 E FARNESS DR STE 101
TUCSON AZ
85712-5617
US

IV. Provider business mailing address

5199 E FARNESS DR STE 101
TUCSON AZ
85712-5617
US

V. Phone/Fax

Practice location:
  • Phone: 520-222-8076
  • Fax: 520-300-7156
Mailing address:
  • Phone: 520-548-4847
  • Fax: 520-300-7156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number49421
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number49421
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number49421
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number49421
License Number StateAZ

VIII. Authorized Official

Name: DR. MOHAMMED MORTAZAVI
Title or Position: DIRECTOR
Credential: MD
Phone: 520-222-8076