=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962504746
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. DAVID M. SPARKS, M.D., PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2006
-----------------------------------------------------
Last Update Date | 01/07/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 415 FAIRVIEW AVE SUITE 201
-----------------------------------------------------
City | PONCA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74601-1923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-762-0202
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 415 FAIRVIEW AVE SUITE 201
-----------------------------------------------------
City | PONCA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74601-1923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. DAVID MICHAEL SPARKS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 580-762-0202
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 22621
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------