Healthcare Provider Details

I. General information

NPI: 1982703690
Provider Name (Legal Business Name): PAUL C SPARKS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 11/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

422 HAMILTON BLVD
SOUTH BOSTON VA
24592-5200
US

IV. Provider business mailing address

PO BOX 1328
KILMARNOCK VA
22482-1328
US

V. Phone/Fax

Practice location:
  • Phone: 434-572-4074
  • Fax: 434-572-4712
Mailing address:
  • Phone: 804-435-8570
  • Fax: 804-435-8037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number0101026595
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: