Healthcare Provider Details

I. General information

NPI: 1689694390
Provider Name (Legal Business Name): CHARISSE Y SPARKS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 03/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1809 W LOOP 281 SUITE 100-131
LONGVIEW TX
75604-2571
US

IV. Provider business mailing address

1809 W LOOP 281 SUITE 100-131
LONGVIEW TX
75604-2571
US

V. Phone/Fax

Practice location:
  • Phone: 816-262-2455
  • Fax:
Mailing address:
  • Phone: 816-262-2455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number022981
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberP1597
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: