Healthcare Provider Details

I. General information

NPI: 1568466035
Provider Name (Legal Business Name): DALLAS FAMILY PRACTICE CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2005
Last Update Date: 12/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 MAIN ST STE B
DALLAS GA
30132-4266
US

IV. Provider business mailing address

PO BOX 89
DALLAS GA
30132-0002
US

V. Phone/Fax

Practice location:
  • Phone: 770-445-1095
  • Fax: 770-445-5361
Mailing address:
  • Phone: 770-445-1095
  • Fax: 770-445-5361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number16148
License Number StateGA

VIII. Authorized Official

Name: JOHN G SPARTI
Title or Position: PRESIDENT/PHYSICIAN
Credential: D.O.
Phone: 770-445-1095