Healthcare Provider Details

I. General information

NPI: 1881798445
Provider Name (Legal Business Name): SUSAN SPARKS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 05/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 BLYTHE BLVD
CHARLOTTE NC
28203-5812
US

IV. Provider business mailing address

PO BOX 601372
CHARLOTTE NC
28260-1372
US

V. Phone/Fax

Practice location:
  • Phone: 704-381-6810
  • Fax: 704-381-6811
Mailing address:
  • Phone: 704-381-6810
  • Fax: 704-381-6811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101238604
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD035678
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0065089
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number2009-00112
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2009-00112
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: