MEDICARE: ESTEL RAY SPARKS O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1123	TN

General Provider Information

NPI Number	:	1265418537
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ESTEL RAY SPARKS O.D.

Provider Business Mailing Address
First Line	:	3321 WARPATH DR
Second Line	:
City	:	CROSSVILLE
State	:	TN
Zip	:	38572-6639
Country	:	US
Telephone Number	:	931-788-6498
Fax Number	:

Provider Business Practice Location Address
First Line	:	473 FRONT ST
Second Line	:
City	:	SPRING CITY
State	:	TN
Zip	:	37381-5198
Country	:	US
Telephone Number	:	423-365-4313
Fax Number	:	423-365-4413

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/19/2005
Last Update Date	:	11/04/2013

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