Healthcare Provider Details

I. General information

NPI: 1831432236
Provider Name (Legal Business Name): IRINA VITA SPARKS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: IRINA DANILOVA

II. Dates (important events)

Enumeration Date: 04/03/2013
Last Update Date: 01/20/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HIGH PARK AVE
GOSHEN IN
46526-4810
US

IV. Provider business mailing address

200 HIGH PARK AVE
GOSHEN IN
46526-4810
US

V. Phone/Fax

Practice location:
  • Phone: 574-364-2888
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number01080898A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: