Healthcare Provider Details

I. General information

NPI: 1831201144
Provider Name (Legal Business Name): RANDAL P SPARKS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 06/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 EAST FAIRVIEW AVENUE
OLIVIA MN
56277-1399
US

IV. Provider business mailing address

600 E PARK AVE
OLIVIA MN
56277-1370
US

V. Phone/Fax

Practice location:
  • Phone: 320-523-1460
  • Fax:
Mailing address:
  • Phone: 320-523-1460
  • Fax: 320-523-1703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO-437
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number52538
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: