Provider Demographics
NPI:1164733366
Name:SPARKS, ERIN VICTORIA (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIN
Middle Name:VICTORIA
Last Name:SPARKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ERIN
Other - Middle Name:VICTORIA
Other - Last Name:ILKANICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:2097 HENRY TECKLENBURG DR
Practice Address - Street 2:SUITE 322W
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5740
Practice Address - Country:US
Practice Address - Phone:843-402-5035
Practice Address - Fax:843-402-5036
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2015-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC329242084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC329246Medicaid
SC329246Medicaid