Healthcare Provider Details

I. General information

NPI: 1356355721
Provider Name (Legal Business Name): JAY WESLEY SPARKS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 04/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4720 N CLASSEN BLVD
OKLAHOMA CITY OK
73118-4837
US

IV. Provider business mailing address

4720 N CLASSEN BLVD
OKLAHOMA CITY OK
73118-4837
US

V. Phone/Fax

Practice location:
  • Phone: 405-528-1220
  • Fax: 405-528-0279
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2504
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: