MEDICARE: MR. LEE BRADFORD SPARKS MD

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	207R00000X	Internal Medicine Physician	35030	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629079678
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LEE BRADFORD SPARKS MD

Provider Business Mailing Address
First Line	:	480 HOPKINSVILLE ST
Second Line	:
City	:	GREENVILLE
State	:	KY
Zip	:	42345-1124
Country	:	US
Telephone Number	:	270-338-5777
Fax Number	:	270-338-5765

Provider Business Practice Location Address
First Line	:	480 HOPKINSVILLE ST
Second Line	:
City	:	GREENVILLE
State	:	KY
Zip	:	42345-1124
Country	:	US
Telephone Number	:	270-338-5777
Fax Number	:	270-338-5765

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

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	12/20/2019

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