Healthcare Provider Details

I. General information

NPI: 1013604602
Provider Name (Legal Business Name): CLARENCE SPARKS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2023
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2417 CENTRAL AVE
ALAMEDA CA
94501-4515
US

IV. Provider business mailing address

2417 CENTRAL AVE
ALAMEDA CA
94501-4515
US

V. Phone/Fax

Practice location:
  • Phone: 510-752-1190
  • Fax:
Mailing address:
  • Phone: 510-752-1190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20A24304
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: