Healthcare Provider Details

I. General information

NPI: 1962504746
Provider Name (Legal Business Name): DR. DAVID M. SPARKS, M.D., PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 01/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 FAIRVIEW AVE SUITE 201
PONCA CITY OK
74601-1923
US

IV. Provider business mailing address

415 FAIRVIEW AVE SUITE 201
PONCA CITY OK
74601-1923
US

V. Phone/Fax

Practice location:
  • Phone: 580-762-0202
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number22621
License Number StateOK

VIII. Authorized Official

Name: DR. DAVID MICHAEL SPARKS
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 580-762-0202