Provider Demographics
NPI:1245405562
Name:SPARKS, WILLIAM TODD (DC)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:TODD
Last Name:SPARKS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13530 73RD AVE N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311
Mailing Address - Country:US
Mailing Address - Phone:612-419-8041
Mailing Address - Fax:
Practice Address - Street 1:13530 73RD AVE N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-2775
Practice Address - Country:US
Practice Address - Phone:612-419-8041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN003756111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN063J7SPOtherBLUE CROSS/BLUE SHIELD
MNU50300Medicare UPIN