Provider Demographics
NPI:1003275413
Name:SPARCC PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:SPARCC PROFESSIONAL CORPORATION
Other - Org Name:SPARCC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMED
Authorized Official - Middle Name:
Authorized Official - Last Name:MORTAZAVI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-222-8076
Mailing Address - Street 1:5199 E FARNESS DR
Mailing Address - Street 2:STE 101
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-5617
Mailing Address - Country:US
Mailing Address - Phone:520-548-4847
Mailing Address - Fax:520-300-7156
Practice Address - Street 1:5199 E FARNESS DR
Practice Address - Street 2:STE 101
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-5617
Practice Address - Country:US
Practice Address - Phone:520-548-4847
Practice Address - Fax:520-300-7156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-12
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ49421207QS0010X, 207RS0010X, 2080S0010X
CA49421208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty