Healthcare Provider Details

I. General information

NPI: 1700839099
Provider Name (Legal Business Name): DAVID MICHAEL SPARKS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
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: 580-762-0219
Mailing address:
  • Phone: 580-762-0202
  • Fax: 580-762-0219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number22621
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: