Healthcare Provider Details

I. General information

NPI: 1609187889
Provider Name (Legal Business Name): PRESTON JEREMY SPARKS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2010
Last Update Date: 07/14/2025
Certification Date: 07/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST
AUGUSTA GA
30912-5867
US

IV. Provider business mailing address

300 HOSPITAL ROAD
FORT GORDON GA
30905
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-8623
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number66904
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberGA69904
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: